Environmental emergencies ii kman 8 15 final

119
Environmental Emergencies II Nicholas E. Kman, MD FACEP Associate Professor The Ohio State University Department of Emergency Medicine

Transcript of Environmental emergencies ii kman 8 15 final

Page 1: Environmental emergencies ii kman 8 15 final

Environmental Emergencies II

Nicholas E Kman MD FACEPAssociate ProfessorThe Ohio State UniversityDepartment of Emergency Medicine

ObjectivesLearner will review the following EmergenciesSnake EnvenomationsSpider BitesMarine EnvenomationsDrowningDysbarismDive MedicineHigh Altitude Illness

Guess That Movie Line

>

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13270155

Snake Envenomations

Wikimedia

Snake Bites

Snake Bites

9000 snakebites annually in US with 2000 treated as envenomations

Est 25 million venomous snakebites occur internationally with 125000 deaths annually

About 12 deathsyear in US60 rattlesnakesImportant to know distribution of venomous snakes in your area

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Statistics

Crotalinae ndash 99 of venomous snakebites in US

65 - rattlesnakes25 - copperheads10 - cottonmouths

Snake Bites Species of Snakes

Viperidae ‑ rattlesnakes cottonmouth copperhead (pit‑vipers)

Elapidae ‑ coral snake only member in US others include cobra and sea snakes

Rattlesnakes CopperheadCottonmouth

Coral Snake (Elapidae)Only 1100 bites in US annuallyDistinct red band bordered by yellow stripes

Neurotoxic component to their potent venom

Short fixed fangs making it difficult to envenomate humans

FileCoral snake close-upjpg - Wikimedia Commons

Coral Snake (Elapidae)

Effects may be delayed up to 12 hrsMild envenomation

localized swelling onlySevere envenomation

Any systemic symptomsNausea vomiting headache mental status neurologic

Respiratory distress

Coral Snake (Elapidae)Initial appearance may be innocuousEarly evacuation to prepare for antivenom administration

Evacuate ALL patients with elapidae bites regardless of symptoms

N Engl J Med Vol 347 No 5middotAugust 1 2002

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

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54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 2: Environmental emergencies ii kman 8 15 final

ObjectivesLearner will review the following EmergenciesSnake EnvenomationsSpider BitesMarine EnvenomationsDrowningDysbarismDive MedicineHigh Altitude Illness

Guess That Movie Line

>

null

13270155

Snake Envenomations

Wikimedia

Snake Bites

Snake Bites

9000 snakebites annually in US with 2000 treated as envenomations

Est 25 million venomous snakebites occur internationally with 125000 deaths annually

About 12 deathsyear in US60 rattlesnakesImportant to know distribution of venomous snakes in your area

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Statistics

Crotalinae ndash 99 of venomous snakebites in US

65 - rattlesnakes25 - copperheads10 - cottonmouths

Snake Bites Species of Snakes

Viperidae ‑ rattlesnakes cottonmouth copperhead (pit‑vipers)

Elapidae ‑ coral snake only member in US others include cobra and sea snakes

Rattlesnakes CopperheadCottonmouth

Coral Snake (Elapidae)Only 1100 bites in US annuallyDistinct red band bordered by yellow stripes

Neurotoxic component to their potent venom

Short fixed fangs making it difficult to envenomate humans

FileCoral snake close-upjpg - Wikimedia Commons

Coral Snake (Elapidae)

Effects may be delayed up to 12 hrsMild envenomation

localized swelling onlySevere envenomation

Any systemic symptomsNausea vomiting headache mental status neurologic

Respiratory distress

Coral Snake (Elapidae)Initial appearance may be innocuousEarly evacuation to prepare for antivenom administration

Evacuate ALL patients with elapidae bites regardless of symptoms

N Engl J Med Vol 347 No 5middotAugust 1 2002

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 3: Environmental emergencies ii kman 8 15 final

Guess That Movie Line

>

null

13270155

Snake Envenomations

Wikimedia

Snake Bites

Snake Bites

9000 snakebites annually in US with 2000 treated as envenomations

Est 25 million venomous snakebites occur internationally with 125000 deaths annually

About 12 deathsyear in US60 rattlesnakesImportant to know distribution of venomous snakes in your area

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Statistics

Crotalinae ndash 99 of venomous snakebites in US

65 - rattlesnakes25 - copperheads10 - cottonmouths

Snake Bites Species of Snakes

Viperidae ‑ rattlesnakes cottonmouth copperhead (pit‑vipers)

Elapidae ‑ coral snake only member in US others include cobra and sea snakes

Rattlesnakes CopperheadCottonmouth

Coral Snake (Elapidae)Only 1100 bites in US annuallyDistinct red band bordered by yellow stripes

Neurotoxic component to their potent venom

Short fixed fangs making it difficult to envenomate humans

FileCoral snake close-upjpg - Wikimedia Commons

Coral Snake (Elapidae)

Effects may be delayed up to 12 hrsMild envenomation

localized swelling onlySevere envenomation

Any systemic symptomsNausea vomiting headache mental status neurologic

Respiratory distress

Coral Snake (Elapidae)Initial appearance may be innocuousEarly evacuation to prepare for antivenom administration

Evacuate ALL patients with elapidae bites regardless of symptoms

N Engl J Med Vol 347 No 5middotAugust 1 2002

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 4: Environmental emergencies ii kman 8 15 final

Snake Envenomations

Wikimedia

Snake Bites

Snake Bites

9000 snakebites annually in US with 2000 treated as envenomations

Est 25 million venomous snakebites occur internationally with 125000 deaths annually

About 12 deathsyear in US60 rattlesnakesImportant to know distribution of venomous snakes in your area

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Statistics

Crotalinae ndash 99 of venomous snakebites in US

65 - rattlesnakes25 - copperheads10 - cottonmouths

Snake Bites Species of Snakes

Viperidae ‑ rattlesnakes cottonmouth copperhead (pit‑vipers)

Elapidae ‑ coral snake only member in US others include cobra and sea snakes

Rattlesnakes CopperheadCottonmouth

Coral Snake (Elapidae)Only 1100 bites in US annuallyDistinct red band bordered by yellow stripes

Neurotoxic component to their potent venom

Short fixed fangs making it difficult to envenomate humans

FileCoral snake close-upjpg - Wikimedia Commons

Coral Snake (Elapidae)

Effects may be delayed up to 12 hrsMild envenomation

localized swelling onlySevere envenomation

Any systemic symptomsNausea vomiting headache mental status neurologic

Respiratory distress

Coral Snake (Elapidae)Initial appearance may be innocuousEarly evacuation to prepare for antivenom administration

Evacuate ALL patients with elapidae bites regardless of symptoms

N Engl J Med Vol 347 No 5middotAugust 1 2002

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 5: Environmental emergencies ii kman 8 15 final

Wikimedia

Snake Bites

Snake Bites

9000 snakebites annually in US with 2000 treated as envenomations

Est 25 million venomous snakebites occur internationally with 125000 deaths annually

About 12 deathsyear in US60 rattlesnakesImportant to know distribution of venomous snakes in your area

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Statistics

Crotalinae ndash 99 of venomous snakebites in US

65 - rattlesnakes25 - copperheads10 - cottonmouths

Snake Bites Species of Snakes

Viperidae ‑ rattlesnakes cottonmouth copperhead (pit‑vipers)

Elapidae ‑ coral snake only member in US others include cobra and sea snakes

Rattlesnakes CopperheadCottonmouth

Coral Snake (Elapidae)Only 1100 bites in US annuallyDistinct red band bordered by yellow stripes

Neurotoxic component to their potent venom

Short fixed fangs making it difficult to envenomate humans

FileCoral snake close-upjpg - Wikimedia Commons

Coral Snake (Elapidae)

Effects may be delayed up to 12 hrsMild envenomation

localized swelling onlySevere envenomation

Any systemic symptomsNausea vomiting headache mental status neurologic

Respiratory distress

Coral Snake (Elapidae)Initial appearance may be innocuousEarly evacuation to prepare for antivenom administration

Evacuate ALL patients with elapidae bites regardless of symptoms

N Engl J Med Vol 347 No 5middotAugust 1 2002

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 6: Environmental emergencies ii kman 8 15 final

Snake Bites

9000 snakebites annually in US with 2000 treated as envenomations

Est 25 million venomous snakebites occur internationally with 125000 deaths annually

About 12 deathsyear in US60 rattlesnakesImportant to know distribution of venomous snakes in your area

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Statistics

Crotalinae ndash 99 of venomous snakebites in US

65 - rattlesnakes25 - copperheads10 - cottonmouths

Snake Bites Species of Snakes

Viperidae ‑ rattlesnakes cottonmouth copperhead (pit‑vipers)

Elapidae ‑ coral snake only member in US others include cobra and sea snakes

Rattlesnakes CopperheadCottonmouth

Coral Snake (Elapidae)Only 1100 bites in US annuallyDistinct red band bordered by yellow stripes

Neurotoxic component to their potent venom

Short fixed fangs making it difficult to envenomate humans

FileCoral snake close-upjpg - Wikimedia Commons

Coral Snake (Elapidae)

Effects may be delayed up to 12 hrsMild envenomation

localized swelling onlySevere envenomation

Any systemic symptomsNausea vomiting headache mental status neurologic

Respiratory distress

Coral Snake (Elapidae)Initial appearance may be innocuousEarly evacuation to prepare for antivenom administration

Evacuate ALL patients with elapidae bites regardless of symptoms

N Engl J Med Vol 347 No 5middotAugust 1 2002

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 7: Environmental emergencies ii kman 8 15 final

Snake Bite Statistics

Crotalinae ndash 99 of venomous snakebites in US

65 - rattlesnakes25 - copperheads10 - cottonmouths

Snake Bites Species of Snakes

Viperidae ‑ rattlesnakes cottonmouth copperhead (pit‑vipers)

Elapidae ‑ coral snake only member in US others include cobra and sea snakes

Rattlesnakes CopperheadCottonmouth

Coral Snake (Elapidae)Only 1100 bites in US annuallyDistinct red band bordered by yellow stripes

Neurotoxic component to their potent venom

Short fixed fangs making it difficult to envenomate humans

FileCoral snake close-upjpg - Wikimedia Commons

Coral Snake (Elapidae)

Effects may be delayed up to 12 hrsMild envenomation

localized swelling onlySevere envenomation

Any systemic symptomsNausea vomiting headache mental status neurologic

Respiratory distress

Coral Snake (Elapidae)Initial appearance may be innocuousEarly evacuation to prepare for antivenom administration

Evacuate ALL patients with elapidae bites regardless of symptoms

N Engl J Med Vol 347 No 5middotAugust 1 2002

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 8: Environmental emergencies ii kman 8 15 final

Snake Bites Species of Snakes

Viperidae ‑ rattlesnakes cottonmouth copperhead (pit‑vipers)

Elapidae ‑ coral snake only member in US others include cobra and sea snakes

Rattlesnakes CopperheadCottonmouth

Coral Snake (Elapidae)Only 1100 bites in US annuallyDistinct red band bordered by yellow stripes

Neurotoxic component to their potent venom

Short fixed fangs making it difficult to envenomate humans

FileCoral snake close-upjpg - Wikimedia Commons

Coral Snake (Elapidae)

Effects may be delayed up to 12 hrsMild envenomation

localized swelling onlySevere envenomation

Any systemic symptomsNausea vomiting headache mental status neurologic

Respiratory distress

Coral Snake (Elapidae)Initial appearance may be innocuousEarly evacuation to prepare for antivenom administration

Evacuate ALL patients with elapidae bites regardless of symptoms

N Engl J Med Vol 347 No 5middotAugust 1 2002

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 9: Environmental emergencies ii kman 8 15 final

Coral Snake (Elapidae)Only 1100 bites in US annuallyDistinct red band bordered by yellow stripes

Neurotoxic component to their potent venom

Short fixed fangs making it difficult to envenomate humans

FileCoral snake close-upjpg - Wikimedia Commons

Coral Snake (Elapidae)

Effects may be delayed up to 12 hrsMild envenomation

localized swelling onlySevere envenomation

Any systemic symptomsNausea vomiting headache mental status neurologic

Respiratory distress

Coral Snake (Elapidae)Initial appearance may be innocuousEarly evacuation to prepare for antivenom administration

Evacuate ALL patients with elapidae bites regardless of symptoms

N Engl J Med Vol 347 No 5middotAugust 1 2002

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 10: Environmental emergencies ii kman 8 15 final

Coral Snake (Elapidae)

Effects may be delayed up to 12 hrsMild envenomation

localized swelling onlySevere envenomation

Any systemic symptomsNausea vomiting headache mental status neurologic

Respiratory distress

Coral Snake (Elapidae)Initial appearance may be innocuousEarly evacuation to prepare for antivenom administration

Evacuate ALL patients with elapidae bites regardless of symptoms

N Engl J Med Vol 347 No 5middotAugust 1 2002

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 11: Environmental emergencies ii kman 8 15 final

Coral Snake (Elapidae)Initial appearance may be innocuousEarly evacuation to prepare for antivenom administration

Evacuate ALL patients with elapidae bites regardless of symptoms

N Engl J Med Vol 347 No 5middotAugust 1 2002

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 12: Environmental emergencies ii kman 8 15 final

N Engl J Med Vol 347 No 5middotAugust 1 2002

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 13: Environmental emergencies ii kman 8 15 final

Signs and SymptomsCheck for signs of envenomation

1 or more fang marks pain edema erythema or ecchymosis Bullae may appear

Systemic effects AMS tachycardia tachypnea resp distress hypotension coagulopathy renal failure hemolysis

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 14: Environmental emergencies ii kman 8 15 final

Snake BitesGrades of EnvenomationGrade 0

Fang marks No envenomation

Grade I Mild envenomation Fang marks Pain and edema at site Local ecchymosis Blistering Necrosis Minimal to no spread of edema proximal to site

Torpy Janet M (04182012) Snakebite JAMA the journal of the American Medical Association (0098-7484) 307 (15) p 1657

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 15: Environmental emergencies ii kman 8 15 final

Moderate56 of bitesSevere painSpreading edema beyond site of bite

Systemic signs ndash nausea vomiting paresthesias muscle fasciculations mild hypotension

Photo by N Kman

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 16: Environmental emergencies ii kman 8 15 final

Severebull Marked swelling of extremity that occurs rapidly

bull Subcutaneous ecchymosisbull Systemic symptoms ndash coagulopathy hypotension altered mental status

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 17: Environmental emergencies ii kman 8 15 final

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 18: Environmental emergencies ii kman 8 15 final

Snake Bite Management

Maintain vital signs (ABCrsquos)Reduce venom effectsPrevent complicated sequelaeMinimize tissue damage

Wikipedia

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 19: Environmental emergencies ii kman 8 15 final

SNAKE BITESImmediate First AidGet away from the snakeStay calmImmobilize the bitten extremity at a position of heart

Apply a constricting band or wrap (Coral Snake)

TRANSPORT TO MEDICAL FACILITY

httpwwwhowitworksdailycomenvironmenthow-to-survive-a-snakebite

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 20: Environmental emergencies ii kman 8 15 final

Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite

Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets

Lavonas et al BMC Emergency Medicine 2011 112

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 21: Environmental emergencies ii kman 8 15 final

Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression

Measure circumference of limb mark leading edge every 15-30 minutes

If signs of envenomation antivenin admin

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 22: Environmental emergencies ii kman 8 15 final

SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 23: Environmental emergencies ii kman 8 15 final

Snake Bite General Wound Care

Cleanse wound thoroughlyTetanus prophylaxisGeneral supportive careOpioid Analgesics

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 24: Environmental emergencies ii kman 8 15 final

Snake Bite Complications

Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring

Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash

Rx-steroids and antihistamines

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 25: Environmental emergencies ii kman 8 15 final

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 26: Environmental emergencies ii kman 8 15 final

QuizA 23 year old male was playing with a copperhead

when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment

A Lecture on the dangers of mixing snakes and alcohol

B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 27: Environmental emergencies ii kman 8 15 final

Name the Actor

>

null

54857273

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 28: Environmental emergencies ii kman 8 15 final

Spider Envenomations

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 29: Environmental emergencies ii kman 8 15 final

Ohiorsquos Biting Spiders

2 main groups of spiders the recluse spiders and the widow spiders

The black widow Latrodectus mactans and the northern widow Latrodectus variolus

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 30: Environmental emergencies ii kman 8 15 final

Widow Spidersbull Black Widow ndash Latrodectus mactansbull Widespread esp SESWbull Garages barns outhouses foliagebull Alpha-latrotoxin causes increased release of multiple neurotransmitters

FileBlack widow spider 9854 loresjpg - Wikimedia Commons

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 31: Environmental emergencies ii kman 8 15 final

Black Widow

bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs

bull Nausea vomiting

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 32: Environmental emergencies ii kman 8 15 final

Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids

Priapism weakness diaphoresis fasciculations may all occur in severe envenomation

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 33: Environmental emergencies ii kman 8 15 final

TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 34: Environmental emergencies ii kman 8 15 final

Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects

httpsenwikipediaorgwikiSicariidaemediaFileBrown_recluse_spider_Loxosceles_reclusajpg

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 35: Environmental emergencies ii kman 8 15 final

Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten

Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor

Necrosis may develop within 3-4 days becoming ulcerated

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 36: Environmental emergencies ii kman 8 15 final

Brown Recluse Venom

Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 37: Environmental emergencies ii kman 8 15 final

Brown Recluse

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 38: Environmental emergencies ii kman 8 15 final

TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 39: Environmental emergencies ii kman 8 15 final

Systemic LoxoscelismRarely correlates with the severity of the skin lesion

Children most at riskFever chills myalgias arthralgias morbilliform rash

DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 40: Environmental emergencies ii kman 8 15 final

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 41: Environmental emergencies ii kman 8 15 final

QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment

A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 42: Environmental emergencies ii kman 8 15 final

The Deep Blue Sea

>

6912

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 43: Environmental emergencies ii kman 8 15 final

The Deep Blue Sea

httpswwwflickrcomphotos7thstreettheatre15250533391

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 44: Environmental emergencies ii kman 8 15 final

Marine Envenomations

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 45: Environmental emergencies ii kman 8 15 final

JellyfishCoelenterates (Portuguese man-of-war true jellyfish

hydroid corals sea anemones corals)Coastal areas of USAbout 10000 envenomations each summer off the east

coast of AustraliaNematocysts are stinging cells on outer tentacleBox jellyfish causes most fatal envenomations

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 46: Environmental emergencies ii kman 8 15 final

Jellyfish

Toxin contains complex mixture of proteins and polypeptides

Most common presentation is painful papular-urticarial eruption

Lesions can last for minutes to hours and rash may progress to urticaria hemorrhage ulceration

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 47: Environmental emergencies ii kman 8 15 final

49

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 48: Environmental emergencies ii kman 8 15 final

50

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 49: Environmental emergencies ii kman 8 15 final

JellyfishSystemic reactions can develop ndash weakness

headache vomiting muscle spasm fever pallor respiratory distress paresthesias

Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 50: Environmental emergencies ii kman 8 15 final

Treatment

ABCs

Inactivate nematocysts

Remove

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 51: Environmental emergencies ii kman 8 15 final

Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available

Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 52: Environmental emergencies ii kman 8 15 final

RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection

httpwwwprwebcomreleases201110prweb8913589htm

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 53: Environmental emergencies ii kman 8 15 final

Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 54: Environmental emergencies ii kman 8 15 final

Echinoderms

Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate

X-ray or ultrasound to look for retained fragments ndash surgery may be needed

Tetanus prophylaxisWatch for infection

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 55: Environmental emergencies ii kman 8 15 final

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 56: Environmental emergencies ii kman 8 15 final

Quiz A patient presents to your emergency department after being

stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment

A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 57: Environmental emergencies ii kman 8 15 final

Drowning

Wikimedia

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 58: Environmental emergencies ii kman 8 15 final

LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 59: Environmental emergencies ii kman 8 15 final

TerminologyDrowning Process resulting in respiratory impairment

from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity

The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air

Drowned refers to a person who dies from drowning

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 60: Environmental emergencies ii kman 8 15 final

DrowningSecond only to MVA as most common cause of accidental death in US

Risk factorsmale sexage lt14 yearsalcohol userisky behaviorLow incomePoor educationrural residencyaquatic exposurelack of supervision

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 61: Environmental emergencies ii kman 8 15 final

Drowning Pathophysiology

Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia

Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia pulseless electrical activity then asystole

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 62: Environmental emergencies ii kman 8 15 final

Drowning Treatment Immediate and adequate resuscitation is most important

factor influencing survivalFor unconscious in-water resuscitation may increase

favorable outcome by 3 timesDrowning persons with only respiratory arrest usually

respond after rescue breaths If no response assume cardiac arrest amp start CPR

Full neurologic recovery is not predicted if victim has been submerged gt60 min in icy water or gt20 min in cool water

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 63: Environmental emergencies ii kman 8 15 final

Predictors of Outcome Early BLS and ACLS improve outcomes (ABCrsquos)Duration of submersion and risk of deathsevere

neurologic impairment after hospital discharge0ndash5 min mdash 106ndash10 min mdash 5611ndash25 min mdash 88gt25 min mdash nearly 100

Wikipedia

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 64: Environmental emergencies ii kman 8 15 final

Diving Medicine

Wikimedia

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 65: Environmental emergencies ii kman 8 15 final

Dysbarism

All the pathologic changes caused by altered environmental pressure

Altitude-related eventUnderwater diving accidentBlast injury that produces an overpressure effect

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 66: Environmental emergencies ii kman 8 15 final

Types

Barotrauma ndash dysbarism from trapped gasesDecompression sickness ndash dysbarism from evolved gases

Nitrogen narcosis ndash dysbarism from abnormal gas concentration (ldquoRapture of the Deeprdquo)

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 67: Environmental emergencies ii kman 8 15 final

Pressure is doubled volume is halvedPV = KEvery 33 ft of descent increases the pressure by 1 atm

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 68: Environmental emergencies ii kman 8 15 final

Boylersquos Bubbles

Boylersquos law states pressure of gas is inversely related to volume

As pressure increases with descent volume of gas bubble decreases as pressure decreases with ascent the volume of gas bubble increases

Air-containing spaces act according to Boylersquos lawLungs middle ear sinuses and gastrointestinal tract

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 69: Environmental emergencies ii kman 8 15 final

Middle Ear SqueezeBarotitis media-Most common diving-related barotrauma

Equalization of pressure via eustachian tube is unsuccessful

Too rapid descent or infectioninflammation

TM is pulled inward amp can rupture

Fullness in ears severe pain tinnitus

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 70: Environmental emergencies ii kman 8 15 final

Middle Ear SqueezePE ndash erythema or retraction of TM blood behind TM or rupture bloody nasal discharge

Reverse ear squeeze occurs on ascentTreatment ndash prevention clear ears during diveIf TM not ruptured ndash pseudoephedrine and oxymetazoline nasal spray

If TM ruptured ndash antibiotic for 7-10 daysSuspend diving activities

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 71: Environmental emergencies ii kman 8 15 final

Other Barotrauma

Barotitis externaAlternobaric vertigoBarosinusitisBarodontalgiaFace mask squeeze

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 72: Environmental emergencies ii kman 8 15 final

Pulmonary Over-Pressurization

A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism

Simple pneumothorax may progress to tension on further ascent

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 73: Environmental emergencies ii kman 8 15 final

Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli

Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise

Cardiac ndash ischemia dysrhythmias cardiac arrest

Neurologic ndash LOC confusion stroke-like sx

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 74: Environmental emergencies ii kman 8 15 final

AGE

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 75: Environmental emergencies ii kman 8 15 final

Arterial Gas Embolism (AGE)

Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding

Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 76: Environmental emergencies ii kman 8 15 final

Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid

is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood

but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas

will be accumulated in the body

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 77: Environmental emergencies ii kman 8 15 final

Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli

If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue

Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 78: Environmental emergencies ii kman 8 15 final

Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS

Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense

Palpable tendernessVague area of numbness around the affected joint

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 79: Environmental emergencies ii kman 8 15 final

Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel

LymphedemaFatigue especially if severe

Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 80: Environmental emergencies ii kman 8 15 final

Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 81: Environmental emergencies ii kman 8 15 final

Cerebral AGE vs DCS II

DCS IIDive must be long

enough to saturate tissues

Onset is latent (often 2-6 hrs)

Spinal cord and brain

Cerebral AGEMay occur after any

type of diveOnset is immediate

(lt10-120 min)Only brain

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 82: Environmental emergencies ii kman 8 15 final

Pulmonary DCS

ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop

Triad ndash shortness of breath cough and substernal chest pain or chest tightness

Cyanosis tachypnea and tachycardia

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 83: Environmental emergencies ii kman 8 15 final

Neurologic DCS

Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction

Brain ndash variety of symptoms and difficult to distinguish from AGE

Scotomata headache confusion dysphasia

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 84: Environmental emergencies ii kman 8 15 final

Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)

Rare but often lethalWeakness sweating hypotension tachycardia pallor

Despite fluids hypotension may not respond until recompression

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 85: Environmental emergencies ii kman 8 15 final

DCS Diagnostics

History is most importantLab used to rule out other conditions andor obtain baseline measurements

CXRECGCTMRITesting should not delay transfer to HBO

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 86: Environmental emergencies ii kman 8 15 final

DCS Treatment

ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 87: Environmental emergencies ii kman 8 15 final

Photo N Kman

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 88: Environmental emergencies ii kman 8 15 final

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 89: Environmental emergencies ii kman 8 15 final

QuizYou are on a plane from Key West to Cleveland

when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do

A Lecture the passenger on diving too close to a flight

B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing

C Intubate and hyperventilate

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 90: Environmental emergencies ii kman 8 15 final

High Altitude Medicine

httpphilcdcgovphildetailsasp

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 91: Environmental emergencies ii kman 8 15 final

High Altitude IllnessRate of ascent

Altitude reached

Sleeping altitude

Individual physiology

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 92: Environmental emergencies ii kman 8 15 final

High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness

Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia

Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided

Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 93: Environmental emergencies ii kman 8 15 final

Risk Factors

History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 94: Environmental emergencies ii kman 8 15 final

High Altitude Medicine

Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE)

High Altitude Pulmonary Edema (HAPE)

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 95: Environmental emergencies ii kman 8 15 final

Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)

Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 96: Environmental emergencies ii kman 8 15 final

AMS

Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses

Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 97: Environmental emergencies ii kman 8 15 final

AMSAvoid further ascent until symptoms have resolved

Descend if no improvement in 24 hours or worsening symptoms

Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 98: Environmental emergencies ii kman 8 15 final

Acetazolamide

For both treatment and prevention of AMSMechanism of action increase urinary excretion of

sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation

Decreases periodic breathing and improves sleeping

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 99: Environmental emergencies ii kman 8 15 final

Acetazolamide

Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent

and the first 2 days at high altitude

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 100: Environmental emergencies ii kman 8 15 final

Dexamethasone

For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema

4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 101: Environmental emergencies ii kman 8 15 final

Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior

to ascent)-modest evidenceProphylaxis against HAPE

Nifedipine 20mg PO q8 for patients with recurrent HAPE

Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 102: Environmental emergencies ii kman 8 15 final

Golden Rules of AMS

0 Itrsquos ok to get AMS Itrsquos not ok to die of it

1 Any illness is AMS until proven otherwise

2 Never ascend with AMS symptoms

3 If you are getting worse go down at once

4 Never leave someone with AMS alone

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 103: Environmental emergencies ii kman 8 15 final

High Altitude Cerebral Edema (HACE)

HACE progression of AMS to life-threatening end-organ damage

Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude

HACE almost never occurs without antecedent AMS symptoms as a harbinger

The progression of AMS to coma typically occurs over 1 ndash 3 days

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 104: Environmental emergencies ii kman 8 15 final

HACE

Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death

Once coma present ndash 60 mortality rateCause of death ndash brain herniation

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 105: Environmental emergencies ii kman 8 15 final

httpwwwaltitudemedicineorgindexphpaltitude-medicinelearn-about-altitude-sicknesswhat-is-hace

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 106: Environmental emergencies ii kman 8 15 final

High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 107: Environmental emergencies ii kman 8 15 final

HACE Treatment

DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs

Gamow bag if descent not possible

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 108: Environmental emergencies ii kman 8 15 final

HAPE

Accounts for most deaths from high altitude illness

Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude

Rarely occurs after more than four days

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 109: Environmental emergencies ii kman 8 15 final

HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses

Cerebral signs and symptoms are common

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 110: Environmental emergencies ii kman 8 15 final

HAPE

Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 111: Environmental emergencies ii kman 8 15 final

HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction

Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells

Impaired clearance of fluid from alveolar space probably has a role

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 112: Environmental emergencies ii kman 8 15 final

HAPE Treatment

Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure

Inhaled beta-agonists

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 113: Environmental emergencies ii kman 8 15 final

Acute Mountain Sickness (AMS)AnorexiaNauseaVomitingInsomniaDizzinessLassitudeFatigueLightheaded

High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa

High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 114: Environmental emergencies ii kman 8 15 final

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 115: Environmental emergencies ii kman 8 15 final

Quiz You decide to climb to the top of Mt Everest While nearing

the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him

A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions
Page 116: Environmental emergencies ii kman 8 15 final

Questions

  • Environmental Emergencies II
  • Objectives
  • Guess That Movie Line
  • Snake Envenomations
  • Slide 5
  • Snake Bites
  • Snake Bite Statistics
  • Snake Bites (2)
  • Coral Snake (Elapidae)
  • Slide 10
  • Coral Snake (Elapidae) (2)
  • Coral Snake (Elapidae) (3)
  • Slide 13
  • Signs and Symptoms
  • Snake Bites (3)
  • Moderate
  • Severe
  • Slide 18
  • Snake Bite Management
  • SNAKE BITES
  • Snake Bites Treatments to Avoid
  • Snake Bite ED Management
  • SNAKE BITES (2)
  • Snake Bite General Wound Care
  • Snake Bite Complications
  • Quiz
  • Quiz (2)
  • Name the Actor
  • Slide 29
  • Spider Envenomations
  • Ohiorsquos Biting Spiders
  • Widow Spiders
  • Black Widow
  • Black Widow (2)
  • Treatment
  • Brown Recluse
  • Cutaneous Loxoscelism
  • Brown Recluse Venom
  • Brown Recluse (2)
  • Treatment (2)
  • Systemic Loxoscelism
  • Quiz (3)
  • Quiz (4)
  • The Deep Blue Sea
  • The Deep Blue Sea (2)
  • Marine Envenomations
  • Jellyfish
  • Jellyfish (2)
  • Slide 49
  • Slide 50
  • Jellyfish (3)
  • Treatment (3)
  • Jellyfish Treatment
  • Removal
  • Echinoderms
  • Echinoderms (2)
  • Quiz (5)
  • Quiz (6)
  • Drowning
  • Slide 60
  • Terminology
  • Drowning (2)
  • Drowning Pathophysiology
  • Drowning Treatment
  • Predictors of Outcome
  • Diving Medicine
  • Dysbarism
  • Types
  • Slide 69
  • Boylersquos Bubbles
  • Middle Ear Squeeze
  • Middle Ear Squeeze (2)
  • Other Barotrauma
  • Pulmonary Over-Pressurization
  • Arterial Gas Embolism (AGE)
  • AGE
  • Arterial Gas Embolism (AGE) (2)
  • Decompression Sickness (DCS)
  • Decompression Sickness
  • Type I DCS
  • Type I DCS (2)
  • Type II DCS
  • Cerebral AGE vs DCS II
  • Pulmonary DCS
  • Neurologic DCS
  • Decompression Shock
  • DCS Diagnostics
  • DCS Treatment
  • Slide 89
  • Quiz (7)
  • Quiz (8)
  • High Altitude Medicine
  • High Altitude Illness
  • High Altitude Illness (2)
  • Risk Factors
  • High Altitude Medicine (2)
  • Acute Mountain Sickness
  • AMS
  • AMS (2)
  • Acetazolamide
  • Acetazolamide (2)
  • Dexamethasone
  • Other Treatments
  • Golden Rules of AMS
  • High Altitude Cerebral Edema (HACE)
  • HACE
  • Slide 107
  • Slide 108
  • HACE Treatment
  • Slide 110
  • HAPE
  • HAPE (2)
  • HAPE (3)
  • HAPE (4)
  • HAPE Treatment
  • Slide 116
  • Quiz (9)
  • Quiz (10)
  • Questions

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