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EMPA 6226

Empa 6226

by christopher316029, Jun. 2012

Subjects: and environmental injuries mgt wound

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Which two tendons of the foot/ankle are prone to injury and are responsible for the eversion and plantar flexion and are located just posterior to the lateral malleolus?	1. Fibularis longus (peroneous longus) and 2. Fibularis brevis (peroneous brevis) p. 331
What extensor tendon, located on the dorsum of foot, on top of the first metatarsal, is responsible for of the first toe, may be injured from dropping a heavy object on the toe?	Extensor hallucis longus p. 331
T/F: injuries to the shin are prone to tendon and nerve damage.	False - yet infrapateller aspect of the knee, lacerations can transect the patellar tendon.
What are the four complications of lower extremity healing?	1. contamination by soil and bacteria is common 2. blood and lymphatics of the foot are under high hydrostatic pressure. Edema is easy- and can retard good wound healing. 3. immobilization of the lower extremity presents logistical challenges and is not well tolerated. 4. blunt force wounds are common, have irregular edges, with surrounding traumatized tissue, and an underlying fracture. p. 331	- compartment syndrome of the foot can occur from severe blunt force injury
T/F: When considering the lower extremity, all lacerations, even those adequately irrigated are regarded as contaminated w/microbes	True p. 331
As with all other parts of the body, most lower extremity wound infections are due to either Staph and/or Strep. Yet, there are others. Name the pathogen associated with the following: 1. Farming accident 2. Wating in fresh water 3. High pressure water system 4. Animal Bites	1. Clostridium Perfrigens- famr 2. Aeromonas Hydrophilia- fresh water 3. Acinetobacter calcoaceticus- high pressure water 4. Pasteurella Multocida and Capnocytophaga Canimorus- animal bite p. 331*
Why is the time interval of onset of an injury to the time reported important?	- increased incidence of infx with delayed treatment. p. 331	- hx taking, lower extremity, p. 331. 1. Td status. 2. conditions that increase risk of infx: DM, immunosuppression, vascular dz, 3. risk for bacteremia: valvular dz, asplenia.
What is the source of most motor control of the foot?	the lower leg is resposible for most of the motor control of the foot. Sensation is in the foot however p. 332	(there are exceptions though- this is a general statement)
Injuries to what 2 nerves can lead to "toe clawing"?	1. posterior tibial nerve 2. deep peroneal nerve p. 332*
What muscles in the foot are innervated by posterior tibial nerve and the deep peroneal nerve?	The posterior tibial nerve innervates the intrinsic foot musculature, and the deep peroneal nerve innervates the extensor digitorum brevis and extensor hallucis brevis muscle. - damage can lead to toe clawing p. 332*	See figure: 48-2, 48-3, p.332
T/F: If a nerve laceration is suspected, both light touch and static 2point discrimination should be tested in the foot and toes, comparing to the uninjured side- two point discrimination varies in the feet and toes, esp in light of significant comorbidities.	True p. 332
Why are open, blunt injuries to the foot most commonly not repaired immediately?	1. because of the risk of infection 2. the contused nerve may regain function w/o intervention. p. 333	report all abnormal nerve findings on physical examination to the surgical consultant
With radiopaque material, when considering a laceration to the lower foot, standard plain film has a > 95% sensitivity for glass and gravel fragments of what size?	glass fragments > 2 mm gravel fragments > 1mm in size. p. 333
What can you do, for possible radiolucent materials when considering a foreign body?	- place radiodense markers around the wound site to better decipher against distortion of the soft tissue shadows p. 333
T/F: Lacerations over the ankle and knee should be examined for joint capsule integrity. However, the detection of joint penetration can be easily done using proper non-invasive physical examination techniques.	False -physical examination techniques are usually inadequate. p. 333
What sign on plain radiographs indicate joint penetration?	Air within joint. p. 333
Injecting saline into the joint capsule is appropriate, to determine is fluid exits wound site, to confirm wound integrity. How much saline should be injected?	>60 cc, to avoid the risk of false negative exam. p. 333
If you are injecting a joint, but fear that the saline would not be adequately visualized, what can you do?	Add flourescein stain and use a wood's lamp to visualize. p. 333
Why is methylene blue, once used to determine joint capsule integrity, no longer encouraged?	- It is discouraged 2/2 the resultant staining of the intra-articular surfaces, which may affect operative management of the intra-articular injuries. p. 333*
When considering dressings and banadages to the lower extremity, a lot has to be considered to prevent further contamination, injury and provide comfort. What is the lower extremity, "general rule" with laceration dressings?	"The smaller the child, the larger the bandage" p. 333
T/F: Recent literature supports that the commercial available mixture of epinephrine and lidocaine on the fingers and toes is not only safe, but may be be advantageous for digital blocks.	True p. 333- however, it does go against the grain of current practice, so caution!
What are the two most common foot nerve block sites?	1. Sural nerve and 2. posterior tibial nerve block p. 333	consider also conscious sedation- esp for plantar surface of the foot.
Where on the foot are topical anesthetic agents, such as lidocaine-epinephrine-tetracaine or eutectic mixture most ineffective?	Epidermis on the sole of the foot p. 333*	HOWEVER, topical preparations are usually effective on the dorsum of the foot and leg. - also bolded!!!!
Lacerations of the lower extremity often require multi-layered closure, using buried 3-0, 4-0 absorbable sutures to approximate the fascia and the dermis, followed by the simple interrupted sutures to approximate the wound edges of the skin, why?	2/2 the likelihood of increased wound tension. p. 334
What suture technique is ideal for wounds under moderate tension in the lower extremity?	Horizontal Mattress sutures p. 334
T/F: in lower extremity wounds, that are not a cosmetic issue, and will be covered, such as proximal to the knee can have staples for closure.	True p. 334	Didn't see that com'n did ya. Thought false...well, WRONG!
Where, in wound management, are deep absorbable sutures avoided?	Those wounds that either are highly contaminated or otherwise prone to infection. p. 334*	Skin staples or horizontal mattress sutures are used.
T/F: On the dorsum of the phalanx of the foot, the skin is attached directly to the periosteum with no intervening layer of subcutaneous tissue. Therefore a laceration of the nail bed places the underlying bone at risk for bacterial contamination.	True p. 334*
What is the "golden period" for wound closure of the foot?	No one knows. However, the longer the delay from injury to closure increases the risk of infection, as the dorsum has a significantly high concentration of bacteria. p. 334*	consider delayed primary closure in the presence of significant contamination
Why are deep sutures inappropriate on the dorsum of the foot?	Because of the close proximity to the bones, tendons and the nerves. p. 334*
When repairing the tibial lacerations, what is a method that improves wound edge strength through fragile skin for suturing?	Placing adhesive tape to the wound edges and then suturing through the tape. p. 334*	* placing additional adhesive tapes is acceptable as well.
When an individual sustains a laceration about the knee, what must be assessed?	Joint capsule integrity. "potential joint capsule penetration and laceration of the patellar and quadriceps tendons p. 334*
What nerve is prone to injury, as it runs over the head of the fibula- laterally, and can be assessed by having the patient invert and dorsiflex their foot.	common peroneal nerve p. 335
Why do popliteal arteries commonly require prompt surgical intervention?	Emergent repair is a must 2/2 the lack of collateral blood flow. p. 335
When are most significant tendon lacerations of the lower extremity repaired after the initial injury?	A few days to a few weeks after the injury p. 335
T/F: Regarding tendon lacerations of the foot: Flexor tendons of the foot rarely need repaired. Extensor tendons may be treated MC with laceration repair of the skin, immobilization and prompt follow up with ortho. However, surgery is likely to be needed, but can be delayed, 2/2 to risk of impaired fxn.	True p. 335
Foot/tendon lacerations. What is the treatment in the ED? (5)	1. skin closure 2. splinting: foot, ankle, and leg 3. initiation of prophylactic abx 4. instruction of non-weightbearing crutch use 5. arrangements for f/u- ortho or podiatry p. 335
What organism MC affects those with open fractures? What is the abx regimen of choice for this?	1. Staph 2. First generation cephalosporin, Ancef, and aminoglycoside Tx in the ED p. 336
An individual sustained a cut to the RLE while hiking. Decided to stand in a stream to irrigate. That was 48 hrs ago, now is experieicing, redness, d/c and extreme pain. What's up: (organism, tx, complications)	1. Aeromonas hydrophilia 2. Aminoglycosides, bactrim, fluoroquinolones 3. compartment syndrome, myonecrosis, and extremity amputation can result p. 336
Describe the reactions caused by the list below. If possible, give examples. 1. inert material 2. organic material 3. Marine foreign bodies	1. inert material- not likely to cause much of a local reaction. Ex: glass metal or plastic 2. vegitative organic matter- most likely to cause a significant reaction. Ex: woods, thorns and spines 3. Marine- sea urchin spines, etc. Cause chronic granulomatous changes. p. 337	also- smooth surface materials are less likely to be a problem than rough surface materials.
What otherwise inert metal, if next to pleural, peritoneal, cerebrospinal or joint fluid can cause systemic toxicity...related to injury	Stupid question- lead, via bullet. p. 337
What is the MC complication of a retained FB?	INfx p. 337	IMPORTANT: retained FB's are characteristiclly resistant to therpies: NSAIDS, Abx- these can produce a partial regression of sxs, but no eradication. Some will regress w/o additional tx once the FB is removed.
Bacteria infrequently are detected following plant thorn injuries. But if there is a bacteria, what is it?	Pantoea agglomerans p. 337	However, MC- fungal infx, esp in immunosuppressed
What more than doubles the likelihood of a FB in a patient?	The patients sensation of FB (adult patient) p. 337	even if no site or source for FB inserion, if this is felt- explore it.
A patient comes to see you. Says that he has this area on his foot that swells, gets red and hot. He gets put on abx, it improves, but once he is done, it comes right back. This has been through three separate courses of abx. No significant medical hx, what are you thinking?	retained foreign body p. 337
Wounds deeper the _____ and wounds whose depth cannot be visualized have a higher association w/foreign bodies. Every effort should be made to inspect all recesses of the wound.	5 mm p. 337*
What three areas of the body, during wound exploration, is blind probing especially dangerous and direct visualization becomes a "must".	1. hands 2. feet 3. face p. 337
What should be done in most cases, but particularly when retained FB is suspected and the FB is not discovered during wound exploration?	Imaging studies p. 337
What 11 items indicated in the text are visible on plain film?	1. metal 2. mammalian bone 3. some fish bones (cod, haddock, grey mullet,red snapper and sole) 4. teeth 5. pencil 6. pencil graphite 7. certain plastics 8. glass (when > 2mm) 9. gravel 10. sand 11. aluminum p. 339*
Why might a FB show up on plain film, but then not another?	It may be a small object, the visible portion may be when the FB is parallel with the x-ray beam, which increases it's density, in turn making it more visible. p. 339
While looking for a soft tissue image, searching for a FB, underpenetration is ideal. But if the radiograph display is on a digital system- what can be done for effect?	Changing the contrast and brightness of the film will have the same effect as under and over penetration. p. 339*
What five items are indicated as not regularly visualized on plain film?	1. wood 2. thorns 3. cactus spines 4. some fish bones 5. other organic material and most plastics p. 340*
What is 100 times more sensitive at differentiating densities, than plain films?	CT p. 340
What imaging modality is best for detecting thorns, spines, toothpicks, fishbones, and plastic foreign bodies?	CT P. 340*
What is one of the pitfalls of CT with regard to FB detection and wood?	Wood FB's may initially mimic air bubbles on the CT image. p. 340*
What posess minimal risk radiation exposure, has >90% sensitivity, in the detection of FB >4 mm to 5 mm in size?	U/S p. 340*	If you didn't get that...smack yourself in the face for me!
T/F: The presence of soft tissue gas can be a hindrance to the detection of FB with u/s.	False - gas has not been shown to reduce the effectiveness of u/s in the detection of FB p. 340
The important aspect of US for the detection of soft tissue FB is the tranducer frequency. What is the depth of the following frequencies? a. 3.5 mHz b. 5.0 mHz c. 7.0 mHz d. 12.5 mHz	The higher the frequency the more superficial the depth a. 3.5 mHz-- 10 cm b. 5.0 mHz-- 7 cm c. 7.0 mHz-- 5 cm d. 12.5 mHz-- 2.0 to 0.2 cm p. 340*
What should be done with the ultrasound to improve its accuracy. Higher frequencies are better at detecting smaller objects, but only at a shallow depth. Lower frequencies can pentrate far deeper, but may miss very small objects.	Use both frequency transducers, taking advantage of these opposing advantages. p. 340*	(even with the use of the CT and plain film, the ultrasound may be used in place of fluroscopy to guide an instrument to the object during retrieval)
What is the MOST accurate diagnostic means to detect wood, plastic, spines and thorns?	MRI p. 341
What diagnostic modality for the detection of FB should not be used for: gravel or medal containing FB?	MRI the ferromagnetic streaks obscure visualization p. 341*
If a FB is suspected, but following wound exploration is not discovered, what should then be ordered?	Plain film...this will detect as many as 80-90% of all FB's. p. 342 for objects not routinely seen on plain film, then the CT is the next exam of choice.
What is the "bottom line" of imaging modalities for FB examinations?	"No single imaging modality is ideal for all types of foreign bodies" p. 342*
What are the "four broad reasons" to remove a FB?	1. potential for inflammation and/or infx 2. Toxicity 3. Functional and cosmetic problems 4. Potential for later injury p. 343, Table 49-2*	- generally, inert, small, deeply imbedded objects that can cause no sxs may be left in place.
What locations of imbedded bullets, by location alone, require immediate removal in the OR?	1. bullets near blood vessels 2. bullets that can cause distal ischemia, thrombus formation, wall erosion, or just lie w/in the lumen of the blood vessel. p. 343
T/F: Patient concern for removal is justifcation enough for removal.	True p. 343
T/F: Because the hand is a deeply mobile and sensitivity, removal of FB is a must and the emergency provider should move quickly to remove the FB and minimize advancing risk.	False: while it is true that the hand is mobile and sensitive, MC the FB exploration and removal should be done by hand surgeon 2/2 to their knowledge of the complex structures of the hand p. 344
Read how to remove specific FB: metallic needles, Wood splinters and organic spines, and traumatic dermal tattooing...p. 345-349 (its quicker than it sounds)	- there is no bold and dunno how to ask a question from this...but its a good review, practically.
When should you get a post-procedure plain film on a FB removal?	When the FB removal was of many FB's p 349*
The decision to close a laceration depends on the risk of infx. What can be closed primarily?	1. wounds in which all foreign contaminants can be removed. 2. the wound is in a location with good blood supply p. 349*	OTHERWISE, delayedprimary closure is ideal.
What should be done, prior to the removal of a FB, when the FB is near a joint or highly mobile region?	The affected area should be splinted prior to removal, to prevent further injury or migration of the object. p. 349*
You are seeing a well controlled DM patient who stepped on a nail, and felt it. It went through the shoes he was wearing. While the most common gram + organisms being staph and strep species, what additional organism are you concerned about?	Pseudomonas Aeruginosa... Most frequent pathogen isolated from plantar wound related osteomyelitis, particularly when the injrury goes through the rubber sole of an athletic shoe. p. 350
Difficulty visualizing and assessing the entire extent of the injury with puncture wounds contributes to the risk of infx; as well as host and wound factors that play a role on infx and healing. Name some pt and wound characteristics	Patient Characteristics: a. elderly b. immunocompromised c. peripheral vascular dz Wound Characteristics: a. contaminated soil or debri b. Containing foreign body c. Injury occurred out doors d. Injury thru shoe or sock e. Injury occurred > 6 hrs prior to the evaluation f. deeper penetration of injury, from jumping, falling or running. p. 350*
What is the treatment for an uncomplicated, clean puncture wound, which presents less than 6 hrs after the event?	Superficial wound cleansing and tetanus prophylaxis. Low pressure (0.5 psi) irrigation of wounds will assist in surface cleansing and allow visualization of the entrance site. p. 350	DO NOT PROVIDE HIGH PRESSURE (7 psi) into the wound site. This has no proven benefit and can drive more of the debri and bacteria deeper into the wound
T/F: Prophylactic abx should be used in all puncture wounds, particularly the immunocompromised.	False - There is no proven benefit of prophylactic abx tx in just any or all puncture wounds. It is recommended in high risk patients, such as: impaired host defense, forefoot injuries, and those through athletic shoes. p. 351
You decide to give someone who sustained a puncture wound prophylactic abx. What strategy should you use for this selection?	- Target the likely causative organism... - first generation cephalosporin, antistaphylococcal pcn, and macrolide. p. 351	Fluoroquinolone is acceptable, bactrim has no psuedomonal coverage...
What are the indications for obtaining plain radiographs for puncture wounds?	1. suspicion for a fx 2. infected wound 3. Wound caused by materials prone to fragmentation (wood, glass, etc) 4. FB sensation reported by the patient p. 351*
What are the indications for getting a CT or MRI for imaging of puncture wound?	1. Suspected deep space infx 2. Persistent pain after injury 3. Failure to respond to treatment. p. 351*
What is the hallmark of all puncture complications?	Persistent pain p. 351	common complications: a. skin tattooing (graphite) b. cellulitis c. localized abscess d. deep, soft tissue infx e. osteomyelitis
What is the treatment for a "deep soft tissue infection".	Parenteral abx and surgical exploration and drainage of pus, excision of necrotic tissue, as well as irrigation of affected areas. p. 351
An individual with osteomyelitis following puncture injury...how long after their injury will they usually show for medical tx?	MC 7 days, and after what felt like a period of improvement. p. 351
Within 72 hours of development of osteomyelitis, this is the definitive diagnostic study...	triple-phase radionuclide bone scan p. 351
A patient has had their bone scan and is dx with osteomyelitis, what must be done for their tx?	Call the consultant prior to administering abx. Cx's are best obtained in the OR and they may wish to begin tx only after this is obtained, or within a time frame that will not prevent adequate speciation. p. 351
A colleague comes to you following a needle stick she obtained when drawing blood on the guy in B-pod, room 15. She wants to know if she has to be on all the HIV meds her friend was on a few years ago?	No, when available the use of the rapid HIV testing, of the source (patient blood or body fluid) can reduce this need for unnecessary prophylaxis in the exposed individual. p. 352
T/F: Regardless of the appearance of a wound from a High pressure device, the history of ANY high pressure device wound demands consultation with surgeon.	True... high pressure devices can cause significant injury along fascial planes and can lacerate skin and bones. p. 352
What should be avoided in high pressure wash hand injuries?	Digital nerve block, this may further increase pressure in the finger compartments p. 352*
Why is it imperative to contact a hand surgeon IMMEDIATELY upon learning of a high pressure wash injury to the hand.	The risk of subsequent amputation is reduced if wide surgical debridement is performed w/in 6 hours of the injury, especially in the cases of organic solvents. p. 352*
On average, digital trauma from epi-autinjectors, is spontaneous resolution, over what time?	Over several hours. Range of resolution is approx. 6-13 hrs. p. 353
Is there any clinical evidence to support the superiority of treatment to clinical observation following digital trauma with epi-pens?	No p. 353*
What is the only proven treatment, if desired, for an individual who sustained an injury to the digiti with an epi-pen injector?	Phentolamine injected into the effected area. p. 353
What are the indications for the closure of mammalian bite wounds?	1. location: is the face or scalp 2. timing: w/in 6 hours of the injury (time dependent upon individual judgement) 3. Wound characteristics: simple and appropriate for single layer closure, no devitalized tissue 4. Lack of underlying injury: no underlying fx 5. Host: no systemic immunocompromising condition. p. 354*
Case reports of bacteremia, sepsis, and death following canine bites in those immunocompromised were caused by what organism?	Capnocytophaga Canimorsus p. 354
T/F: Primary wound closure in those who sustained a dog bite, who are immunocompromised has not been linked to increased risk of systemic infx, therefore it is safe to provide primary closure.	False - while it is true that wound closure is unlikely to lead to systemic infx from capnocytophaga canimorsus, current practice is to AVOID primary wound closure in pts with systemic immunodeficiencies. p. 354*
What are the 6 bite wounds at a high risk for infection?	1. cat or human 2. Livestock 3. Monkey bites 4. Deep Puncture wounds 5. Hand or foot wounds 6. Bites in the immunosuppressed patients p. 354*	See Chart: 354, table 50-5...provides a review of the source, organism as well as recommended abx tx. The whole table is beneficial and should be reviewed.
Only 5% of untreated canine bites will become infected. What percent of cat bites risk being infected?	80% - they have sharper and narrower teeth- pentrate more deeply. p. 354	Plus they're just nasty little devils
T/F: The prudent response to a bite from cat or dog is to treat all infected wounds and to prescribe abx's for high risk uninfected wounds.	True p. 354*
Why should dicloxicillin, e-mycin, or clindamycin not be used alone for the treatment of cat bites?	Their spectrum does not include Pasteurella Species p. 354-355*
Pen Vk and ampicillin are acceptable abx for Pasteurilla Multicida (T/F)	True - though augmentin is widely, acceptably, used. - for pcn allergies: Doxy or Cefuroxime for cats and Clinda + Fluoroquinolones for dog bites p. 354
Child is presented to you with low grade fever, malaise, HA, nausea, and anorexia. She was scratched by her kitty approx 7-12 days ago. What is the name of the organism?	Bartonella Henslae - cat scratch disease... p. 355	PE- of course would have lymphadenopathy on the associated side of the scratch MC: no need for Abx treatment. However, if needed: 5 days zithromax.
What is generally more serious of a bite, human or animal bites?	Human p. 355
What can result from rat bite, urine or feces (though rare)	Rat-bite fever. - caused by Streprobacillus Moniliformis (N. America) or Spirillum minus/minor (More common in Asia) p. 355	Onset is MC: 3-7 days. begins with rigors and fevers that progress to migratory polyarthralgias and maculopapular petechial, purpuric rash. Infx can spread to vital organs...tx is PCN, doxy, tetracycline.
What organisms are associated with livestock and game animals?	1. brucellosis 2. leptospirosis 3. tularemia p. 355
What organism is associated with saltwater bites?	Vibrio species p. 355
What is transmitted by monkeys and other non-human primate bites, that cause myelitis and hemorrhagic encephalitis leading to death in 70% of cases?	Cercopithecine Herpesvirus 1, also called Herpes B virus p. 356
What is the maximum wounding potential of a bullet determined by?	The bullets mass and velocity p. e38	Of course the tissue traversed has an impact too.
What determines the nature of a bullet wound?	the missile and the tissue characteristics p. e38	Missile Characteristics: inherent- size, shape and construction. Conferred by Weapon too: logitudinal and rotation velocity Tissue Characteristics: elasticity, density and anatomy. Elastic lung/muscle. Dense- brain, liver.
The severity of a bullet wound is determined by what 2 things?	1. bullet's orientation during it's path thru the tissue 2. whether the bullet fragments and deforms e38*
T/F: Sonic pressure wave from a bullet can cause a significant amout of damage to the wound site.	False p. e38 - no part in wounds.
What happens when soft tissue is struck with sufficient velocity, by soft or hollow point bullets?	The bullets deform into a mushroom shape, which increases the surface area and the amount of tissue crushed. p. e38
The crushing of tissue depends on what 6 things?	1. angle of the projectiles entry 2. Bullet deformation 3. Bullet fragmentation 4. Bullet jacket 5. Hollow-point and soft-point bullets 6. Bullet velocity and fragmentation e38-39
What structure in the body, that when struck can become a second projectile and crush tissue?	bone p. e-38*
What allows the bullet to be protected from "stripping" and allowing a fast velocity?	Jacket casings (copper and copper alloy)...such as the "full metal jacket" used by the military p. e-38	- the absence of the casing at the tip and hollow tip, allows the projectile to weaken, mushrooming, which increases the diameter of the projectile.
Which is likely to cause more damage to tissue, civilan bullets or military bullets?	Civilain bullets... - they are predominantly soft tip or hollow tip bullets, so that they will mushroom on contact, causing a greater cavitation. p. e38
Projectiles (bullets) can penetrate tissue based on velocity, but only until that velocity is impaired by what?	Mushrooming (mishaping) of the bullet tip...the greater the bullet diameter expansion from mushrooming, the less the depth of penetration e39
You are looking at a radiograph on an arm where a kid sustained a shot, getting caught in gang cross fire, on his way to church. There is an undeformed bullet and no evidence of a fracture. How bad is the tissue damage (minor, major, subtle, but critical)?	Minor e39 unless of course near a nerve or vessel
What is the most important factor to consider regarding bullet wounds?	Location is the most important factor- a bullet of low wounding potential can cause severe wounds if it passes through a vital structure p. e39
Permanent damage done in wounds of the extremities is a result of structures being hit by what? (3)	1. intact bullet 2. bullet fragments 3. secondary missiles. p.e40
While the yaw produced by a military bullet does not usually occur until after 12 cm of deapth, the civilian one will occur MC on contact. This means that the military bullets will not generally cause much damage to certain areas and more damage to others, Which is which?	- Not common for military bullets to cause extremity damage, as it will typically have enough velocity and undisturbed course- causing entry and exit wounds with little yaw - however, significant damage can be caused to chest and abdomen can be lethal- 2/2 to >12 cm depth and greater likelihood to produce yaw. p. e40
T/F: The bullet's calliber is an excellent indicator of it's wound potential.	False - not at all a valid indicator of wounding potential e40
Gunshot wounds can cause comminution fractures, what of these causes the increased likelihood of delayed union or non-union of the fracture?	Vascular compromise p. e41* Wound infections are common in this group. Monitor for compartment syndrome too...consider fasciotomy if need.
In trunk wounds caused by bullets, what is needed to determine if laparotomy is needed?	Analysis of the bullet path p. e41* Next question, what diagnostic tests are helpful for this (4)	1. two radiographs in planes, separated by 90 degrees. 2. CT 3. Ultrasound 4. DPL
What should raise the question of whether the diaphragm or abdomen has been penetrated by a bullet?	Any bullet below the nipple line p. e41
What is needed if peritoneal penetration by a bullet is either certain or suspected?	Laparotomy p. e.41
A gun shot wound to the neck has occur in a gangbanger. Your colleague orders a CT angio of the neck and tells you, "if this comes back NML" he'll be alright. You review the chart and See blood work, CXR, and CT Angio look good. Was that all that needed to be considered?	Esophageal evaluation must be examined- if evident on CT great, if not, does not mean not NML. (neck and mediastinal injuries) p. e41
Radial pattern fractures of the skull from the bullet, is this an entrance or exit wound?	Entrance - less so for exit p. e41
T/F: The entire wounding potential of a shot pellet is likely to be delivered to the target tissue, with no exit wound.	True p. e42*
The most severe firearm wounds from a shotgun, are from close or distant ranges?	Close range p. e42	After close range shot, external examinationof the patient, particularly after volume resuscitation does not disclose severity of the internal injuries.
What is more predictive of outcome following a gunshot wound to the extremity: major neural injury, major vascular injury, or major fracture injury?	Neural injury p. e42
Explain the billiard ball effect caused by close range injury shotgun pellets.	Exactly as it sounds: when an individual is struck at close range with tightly packet pellets, those in the lead are slowed initially, until struck from those that follow. So it is often difficult to determine, long vs short range firing. p. e42*	However, MC: only one entrance wound hole, as a is close range injury. Multiple skin entrance wounds...same as the pellet spread on radiograph, long range.
T/F: newer designed BB guns can cause fatal injuries.	True - "Air guns should not be considered toys" p. e42**	May seem as a simple scalp wound, but actually be: scalp, skull and brain injury
Radiographic localization of a bullet requires what?	1. two views on plain film at 90 degrees 2. tomographic image - CT of the head and body is often useful for anaylsis of bullet path p. e42
What is the reason that a "path of entrance" wound for a bullet does not match it's present location?	"It reached it's present location via embolization p. e42
You perform a cardiac echo on a patient, because you have to keep performing U/S because your numbers are low 2/2 not getting number credits in spite of how many you have done, and you notice what looks like a bullet or pellet in the cardiac chamber. The patient remarks that he got shot by a friend in the leg a few months ago. What happend and what should be done? Why?	1. it embolized to the heart via venous flow 2. it needs to be removed immediately, call Cardiothoracic surgeon 3. Missiles can continue to embolize and have been known to cause a stroke in CPR patients... p. e-42
You do a radiograph on a patient, because of a GSW. You examine the site of entrance and suspected track and the fact that there is no entrance, you scan this area. Still no bullet. What do you do?	Additional radiographs and fluoroscopy to find the bullet are mandatory p. e42
Where is bullet induced lead poisoning MC (3)?	1. intra-articular missiles 2. disk space 3. bursal locations of bullet fragments because of the solubility of the lead in synovial fluid p. e42*	lead fragments in the brain are actually benign, unless they are copper plated.
Why should intrarticular fragments (from bullets) be removed?	To avoid both the mechanical trauma and the destructive synovitis that lead can cause. p e43*	- This can be rapid, but MC takes years. Advise a patient to seek treatment when develop: HA, abdominal pain, personality changes, or neurologic sxs.
Preserving evidence is important. When cutting clothes off of a patient you are preparing to assess, what should be avoided?	do not cut through knife or bullet holes. p. e43*
Preserving evidence is important. If possible try to minimize further damage from cleaning, if uncertain or as a general rule, what should be done prior to all the cleaning of wounds?	Photograph these areas p. e43
T/F: When descrining the patient wounds following gunshot, describe all entry and exit wounds in great detail. Location, size and shape.	False... while you should describe the location, size and shape of all gun shot wounds, you should not report this as entrance or exit wounds. p. e43*
What is the prototype for freezing injury, but is only seen when ambient temperatures are 'well below freezing"?	Frostbite p. 1331
What are the two most common, non-freezing cold injuries (which occur as a result of exposure to wet conditions when temperatures are above freezing)?	1. trench foot and 2. Chillblains p. 1331
What occurs as a result of sustained, prolonged cooling, and accelerated by wet conditions. With the peripheral nerves most sensitive to this form of injury.	Trenchfoot. p. 1331
What begins as tingling to numbness in the affected area. Appears as pale, mottled, anesthetic, pulseless, immobile and does not seem to change after rewarming. Hyperemic phase then begins, assoc with severe burning. Next 2-3 days, edema develops and bullae form. Anesthesia may persist, or development of gangrene and tissue sloughing. Can result in permanent disability.	Trench foot p. 1331
What is the tx for trench foot, aside from removal of inciting crap?	Feet should be kept clean and dry bandages applied, affected limbs elevated, and the patient should be monitored for signs of infx. Vasodilators and oral Prostaglandins have been shown to improve circulation too. p. 1331
What is caused by mild, intermittent exposure to damp, nonfreezing ambient temperatures, and can cause mild, but uncomfortable inflammatory lesions of the skin?	Chillblains or Pernio p. 1331
What causes early tingling, then numbness of the effected tissues. Followed by erythema, edema, cyanosis, nodules and plaques. Pts often c/o itching, burning. Rewarming can cause tender "blue nodules"- persisting for several days.	Chillblains (pernio) p. 1331	MC in women and children - Those with Raynaud's and other Immunologic conditions, as well as those in a household w/inadequate heating and lack of warmth
What is the tx for chillblains (pernio)?	Supportive: warm, dry bandages, elevation. Additionall peripheral vasodilators (nifedipine 20 mg tid) as well as prostoglandin may be useful. p. 1331
A female patient, equestrian rider, comes to see you for pain in thighs and buttocks following a long ride in the cold. What does she likely have?	Panniculitis... - mild degrees of necrosis of the subcutaneous fat tissue that develops during prolonged exposure to temperaturesjust above freezing. p. 1331
What condition is caused by a hypersensitivity to cold air that in rare conditions can lead to anaphylaxis?	Cold Urticaria p. 1331	Tx: Antihistamines are the recommendation for acute cases.
What are the high risk groups for cold injuries:	1. Miltary personnel 2. Outdoor workers 3. Elderly 4. Homeless 5. People who abuse drugs or alcohol 6. Those with Psych conditions. p. 1331
What are the four broad factors that can influence the risk likelihood of frostbite?	- Environmental - Individual - Behavioral - Health related/Physiologic p. 1332*
Who is frost bite MC to occur in: men or women?	Men p. 1332	This is likely 2/2 to occupation/leisure activities. Women are more susceptible to cooling and cold injuries, 2/2 to their smaller size and surface area-to-mass ratio.
What strongly increases injury rate in cold injuries?	Wind - it markedly increases convective heat loss and reduces insulation value of clothing, which in turn increases risk of frost bite p. 1332
What is skin temperature when frostbite occurs?	< 0 degrees C (<32 F) p. 1332	Very important, aside from wind and temperature, merely touching a cold materials such as metal also significantly increases the risk. Touching this when the metal is -15 degrees C can cause frostbite in 2-3 sec.
A friend of yours was wanting to sell a "safe" ointment to Alaskans- for winter frostbite protection. Whatcha think?	He is a fraud who will get sued. Deny you know him. Ointments increase the risk of frostbite on face and head. p; 1332	Additionally: Smoking, drinking alcohol, not wearing protective gear- even wearing constrictive clothing, prolonged stationary posture- risk of freezing and non-freezing injuries.
What is the patholophysiological "critical event" in frostbite?	endothelial damage at the point of "thaw". p. 1332 (see next slide)	Immediately after freezing and thawing, an arachidonic acid forms, which promotes vasoconstriction, platelet aggregation, leukocyte sludging, and erythrocyte stasis- leading to venule, arterial thrombosis and ischemia, necrosis and dry gangrene.
What are the three zones of frostbite injury?	1. Zone of hyperemia- MC proximal, superficial and least damaging and severe. 2. Zone of stasis- severe, but reversible damage 3. Zone of coagulation- MC distal and is most severe. p. 1333	FYI least to greatest risk of frostbite: 1. cartilage 2. ligament 3. blood vessel 4. cutis 5. epidermis 6. bone 7. Muscle 8. nerve 9. bone marrow
T/F: Determining tissue viability (following frostbite) visually is very difficult in the first few weeks of injury, sometimes it can only be identified after gangrene is well demarcated and sloughed.	True p. 1333
Classification of frostbite injuries: Numbness, erythema, swelling, desquamation, dysesthesia	First degree frost bite p. 1333, table 202-3*	also called frost nip excellent prognosis
Classification of frostbite injuries: blisters on the skin	Second degree frost bite p. 1333, table 202-3*	good prognosis
Classification of frostbite injuries: tissue loss involving the entire thickness of the skin. Can be associated with hemorrhage blisters and blue discoloration of the skin. Pt c/o limb feeling like a "block of wood	Third degree frost bite p. 1333, table 202-3*	poor prognosis
Classification of frostbite injuries: tissue loss involving the entire thickness of the part, including deep structures, resulting in loss of the affected part	Fourth degree frost bite p. 1333, table 202-3*	extremely poor prognosis
Because classification of cold injuries may be difficult in the acute phases, what two terms are used to discribe depth of injury?	superficial or deep p. 1333
T/F: Early imaging studies are useful prognostic indicators for frostbite, esp since cold injuries are difficult for the patient to detect 2/2 to absent sensation and cold reduced swelling.	False - not helpful diagnostically or prognostically. p. 1333
Why is prehospital heating discouraged in frostbite injuries?	Dry heat can cause further injury. Thawing should only be attempted when the risk of refreezing is eliminated. p. 1334*	Analgesia needs to be available early when rewarming is started- as this is very painful.
Once in the emergency department, frostbite injuries are managed how?	Rapid re-warming is the core of frostbite therapy and should be initiated as soon as possible. The injured Extremity should be placed in gently circulating water at a temperature of 40 degrees C to 42 degrees C (104-107.6C) for approximately 20-30 minutes, until the distal extremity is pliable and erythematous. p. 1334*
What is applied to clear and hemorrhagic blisters to combat the arachidonic acid cascade?	Aloe vera cream every 6 hrs. p. 1334*
What is the core tx of frostbite injuries, p. 1334 Table 202-4 (7 things)*	1. Immersion in or application of 40-42degrees C until affected area pliable and erythematous. 2. Topical aloe vera q 6 h.. 3. No blister or soft tissue debridement acutely 4. Meticulous local care 5. Tetanous immunization 6. Parenteral narcotics for pain mgt 7. Motrin 12 mg/kg/day PO in devided doses
What is the optional treatment for frostbite, according to p. 1334, Table 202-4 (3 things)*	1. Topical bacitracin for infx prophylaxis 2. PCN G, 500,000 IV q 6 h for prophylaxis for susceptible organisms 3. Topical silver sulfadiazine cream for prophylaxis- NOT ON FACE.
Body temperature fall from heat loss 2/2: (4)	1. Conduction: transfer of heat from direct contact down and temp gradient, from warm body to cold environment 2. Convection: transfer of heat by actual movement of heated material- such as winds disrupting layer of warmth around body 3. Radiation: radiation of heat to surrounding areas- from non-insulated body areas 4. Evaporation: of water p. 1335	- Hypothalmus controls heat regulation. - Therefore if there is impairment for any reason, the risk is greater: dementia, intoxication, trauma.
What are the indicated causes of hypothermia (8)?	1. Accidental 2. Metabolic disorders 3. Hypothalmic and CNS dysfunction 4. Drugs 5. Sepsis 6. Dermal Disease 7. Acute Incapacitating Illness 8. Massive fluid or blood resuscitation p. 1336*- Table 203-1
What EKG anomaly is characteristic, but not pathognomonic for hypothermia?	Osborne waves (J waves) p. 1336	Additional EKG changes: T wave inversion PR,QRS and QT prolongation Muscle tremor artifact Osborn wave Dysrhymia
T/F: The hypothermic myocardium is extremely irritable, and ventricular fibrillation may be induced by a variety of manipulations and interventions that stimulate the heart, including rough handling of the patient.	True p. 1336
Why is aspiration pneumonia common in hypothermia?	Initially the patient may be tachypneic, however, bradypnea develops as well as bronchrorrhea. The collection of secretions, and the depression of cough and gag reflex make this likely. p. 1336
What direction does the oxyhemaglobin dissociation curve move, in hypothermia?	Leftward... p. 1336	treat with oxygen
Cold inhibits many activities and functions: a. acid base? b. Kidney's c. Platelet function? d. Endocrine?	a. No uniform pattern b. Kidney's- lose concentrating ability and cause a cold induced diuresis c. Platelets- inhibition of fxn, coagulopathy d. Endocrine- fairly well preseved. However, pancreatitis and pancreatic necrosis can occur and hepatic fxn may be depressed by cold. p. 1336-1337
What should be done to treat hypothermia?	- supportive measures, and specific rewarming techniques..."the patient should be removed from the cold environment, wet clothes removed and the patient dried". p. 1337	REMEMBER: Careful handling of the hypothermic patient, as agressive handling can cause ventricular fibrillation of the irritable hypothermic myocardium.
How long should one wait to start CPR on the hypothermic patient, spending time palpating pulse as well as attempting to detect respirations?	45 seconds p. 1337*
Most commonly dysrhythmias that occur in the hypothermic patient represent an immediate threat to life, how will most resolve/be treated?	Most rhythm disturbances: sinus brady, a-fib or flutter require no therapy and will often revert spontaneously with rewarming. p. 1337*	Antiarrhythmic and cardioactive drugs are unpredictable in the hypothermic heart...and atropine, pacing, and countershock are relatively ineffective...hypothermic heart is largely resistent.
You are treating a hypothermic patient who is in V-fib, who is refractory to tx. What needs to be done?	The patient needs to be rewarmed. p. 1337*	AHA recommends one shock. Then CPR. There may be second shock delivered only when core temperature is warmed to: 86 degrees F.
What are some drugs to consider in the hypothermic patient?	- IV thiamine, 100 mg - 50-100 mL of 50% glucose - abx - steroids...hydrocortisone 100 mg p. 1337
What are some rewarming techniques (3)	1. Passive Rewarming 2. Active external rewarming 3. Active core rewarming at 104F p. 1337, Table 203-3
What is core temperature after drop?	It is described as the return of cold blood to the core induced by external rewarming and peripheral vasodilation. Yet, may also be from conduction of heat from the warmer core to the colder peripheral tissues. p. 1337-1338
Why does active external rewarming risk HoTn and hypovolemia?	Because the active EXternal rewarming risks peripheral vasodilation. p. 1337
What is inhlation rewarming?	Administration of warmed, humidified air or oxygen through a facemask/ET tube...to prevent heat loss from the lungs- which accounts for 30% of metobolic heat losses. The temperature of the gas delivered into the mask of ET/Tube should be warmed to 104 degrees F/40degrees C. p 1337	- IV fluids, if provided should be warmed to the same 104 (40)
A young patient is brought to the ER and is hypothermic. A nurse runs to get fluids and places them in the microwave. Your friend says, "as long as they feel warm, but are not too hot to boiling they'll be fine...anything helps right?". Once you realize he's being serious, what should you do?	Stop the nurse. Rewarming to 40C/104F is approved and appropriate. However, this must be checked- Temperatures >50C/122F can cause airway burns on humidified air and hemolysis in the fluids. Which could be clearly self defeating... - Oh, and "the microwave guys, really? Don't let me ever see that again". p. 1338*
T/F: Firm guidelines on rewarming hypothermic patients cannot be given.	True - no prospective controlled studies comparing various rewarming strategies have been done in humans. p. 1338*
At what temperatures (in hypothermia) are the incidence of dysrhythmias low and the rapid rewarming rarely necessary?	> 30 degreesC/>86degreesF p. 1338*	The most important consideration for rewarming techniques in the hypothermic patient: their cardiovascular status, then their temperature. p. 1338
A patient is on the way to you in cardiac arrest and hypothermic. They have the patient successfully intubated and have done one shock and CPR for 45 minutes (total, family and medics). Core temperature: 70 degrees. The paramedics want to know if they should continue enroute, or if you are willing to "call it". Additionally, if there are any medications you want, etc. What's your response doc?	Contine current priority and CPR. No medications at this time. Cannot call this patient until assessed, they have to be warmed to 30-32degrees C, without response to call it. Medications are largely not very effective in htese patients. Aggressive rewarming and my PE are going to determine this... Death is defined as failure to revive after warming. p. 1338
Body temp is regulated thru delicate balance: heat production, accumulation and dissipation. Body has several mechanisms to dissipate heat, what are the four provided?	1. Radiation: transfer heat by electromagnetic waves- from warmer to colder objects 2. Conduction: heat exchange between two surfaces in direct contact 3. Convection: heat transfer by air/liquid moving across surface 4. Evaporation: loss by vaporization of water (sweat) p. 1339	When temp <95degrees F, radiation accounds for 60% loss, and evaporation 30%. > 95degrees, body can no longer radiate heat, but instead evaporation (which deceases when humidity goes up)
What are the four physiologic responses to heat?	1. dilated blood vessels (explains why HR gooes up), particularly in the skin 2. increase sweat production 3. decreased heat production 4. and behavioral heat control p. 1339
What time parameters are generally accepted for heat related acclimatization and declimatization?	1. acclimatization: 7 days to few weeks 2. declimatization: 1-2 weeks p. 1339
How does one prevent exertional heat injury?(5)	1. avoidance of exercise or strenuous physical activity 2. acclimatization 3. hydration 4. breaks from the heat 5. education- about techniques and tactics of prevention, etc. p. 1340
There are many paths for one to experience heat injury, name the three provided.	a. classic heat injury (from environment, not related to activity) b. exertional heat injury- affects individuals who participate in physical sporting events c. Confinement hyperpyrexia p. 1340	Confinement hyperpyrexia, affects 3 groups: 1. children locked in cars 2. illegal immagrants abandoned inside locked vehicles 3. when workers are occupationally exposed to heat inside a closed space.
Most heat disorders are minor and one major. Name them (5,1)	Minor Injury: - heat edema - prickly heat - heat syncope - heat cramps - heat exhaustion Major heat injury: - heat stroke p. 1340
Heat edema is self limiting process caused by peripheral vasodilation. What two hormones secreted in response to this worsen its course?	Aldosterone and Anitdiuretic hormone p. 1340	No need for tx, resolves in few days to up to 6 weeks. Support stalkings and elevation of extremities is appropriate. DO NOT give diuretic this will just provoke complications.
Patient comes to see you with pruritic, maculopapular rash all over back and chest following an outdoor concert at the speeway. Itching is driving him nuts. What is it and how is it treated. he tried baby powder, no relief.	Prickly heat - po antihistamines, will resolve. Wear loose clothing, clean dry clothing. p. 1340
A guy who just started working for the city mowing grass and cleaning outdoors comes to see you because his calves are sore and "tight" causing a lot of pain. Took a friends Vicodin, no relief.	Heat cramps. Opioids are often on their own not enough, though most mild cases are self limiting. - provide: Cool environment, IV or PO fluid and salt For mild cases, or if overwhelming number of pts require tx, 0.1-0.2% saline solution can be given PO. Two 10-grain (650mg) salt abs dissolved in quart of wate provide a 0.1% saline solution p. 1340*
What is heat tetany and the tx?	Heat tetany: hyperventilation resulting in Resp Alkalosis, paresthesia of extremities and circumoral paresthesia or carpal pedal spasms Tx: remove the patient from the heat and decrease resp rate. p. 1341
What are the two different ways to heat exhaustion?	1. Water depletion 2. Sodium depletion p. 1341
43 y/o female presents with HA, Nausea, vomiting, malaise, dizziness, muscle cramps. She appears to have dry mucous membranes, she is tachycardic, and HoTn. Her temperature is 103.5, after being outside in the garden most of this July afternoon. She has remained lucid and appears to be neurologically intact. What is up?	Heat Exhaustion p. 1341
How is heat exhaustion treated?	Volume and electrolyte replacement and rest. IV fluids of 1-2 L may be necessary. Consider med hx- may need admission if CHF, other dx making fluid and electrolyte replenishment hard. p. 1341
T/F: Patients with heat exhaustion, once removed from the heat environment and provided tx should not progress in sxs.	False, even after removal from heat and provided tx, and patient with heat exhaustion can still go on to have a heat stroke. p. 1341
What should be done with the patient who is being treated for heat exhaustion who was removed from the heat and provided fluid replacement for thirty minutes?	Should be aggressively cooled until their core temperatures drop to 39degrees C/102 degrees F. p. 1341*
What heat related injury has a mortality of 30-80% and universally fatal if left untreated?	Heat stroke p. 1341
What are the two cardinal features of a heat stroke?	1. hyperthermia >40 degrees C/104 degreesF 2. AMS p. 1341*
What is an early neurologic finding in heat stroke?	Ataxia, the cerebellum is particularly vulnerable to heat changes in the environment. p. 1341	However, any neurologic finding can be present in heat stroke
What, if delayed, in the treatment of heat stroke increases mortality rate?	Cooling p. 1341
What is the goal of therapy in the heat stroke patient?	Immediate cooling and support of organ system function. p. 1342*
What is the prehospital recommended mgt for heat stroke?	Removal from heat, spray with warm water and apply cooling fans, or sit under the down draft of helicopter. Additionally, may consider applying ice packs to neck, axillae and groin. IV fluid boluses for those individuals with dehydration is a must as well. p. 1342*
You have a patient who is wheeled into bed 13 with suspect heat stroke. Paramedics removed from heat and provided passive cooling and ice packs. Your attending says: "Why not provide tylenol or dantrolene to bring temp down". What do you say?	"Are you serious? Please tell me this is just a pimp question. These do not work and can actually lead to adverse outcomes. " p. 1342
What is the goal temperature of cooling strategies for heat stroke related issues, to avoid overshooting and in turn causing hypothermia?	39degrees C/102 degrees F p. 1342*
What is the most RAPID method of cooling a heat stroke victim?	Cardiopulmonary bypass... - though a logistical and practical nightmare p. 1343	Colling blankets are not a good montherapy ICe packs to neck, groin and axillae also only adjunctive therapy, not to be used alone IV cooled fluids- not effective
What methods of cooling in heat stroke are not recommended?	1. cooling blankets (unless the only thing available) 2. cool water gastric,urinary bladder, rectal, or peritoneal lavage 3. Cold water IV infusion p. 1342, Table 204-3
What can happen to the liver in heat stroke?	Thermal injury p. 1343
What are some special populations of peope at risk for heat emergencies?	1. > 75 y/o 2. < 4 y/o 3. Those with limited mobility 4. Those who are taking antipsychotics 5. Those taking tranquilizers 6. Those taking anticholinergics 7. Those taking cardiac meds: BetaBlockers, CCB, and vasodilators. 8. Those taking otc sleep aids or stimulants. p. 1344
What are the most important venomous insects known to humans?	Hymenoptera - these cause more fatalities from stings than any other Arthropod p 1344
What are the three subgroups of Hymenoptera?	1. Apidae (bumblebees and honeybees) 2. Vesipdae (Yellow jackets and hornets) 3. Formicidae (ants) p. 1344	- africanized honeybees attack w/>10 times more force (quantity of bees) and can cause multiorgan failure- however, their venom is no worse than regular honeybee
Most allergic reactions to hymenoptera occur from which subgroup?	Vespids- wasps and yellow jackets p. 1344	While honeybees are generally docile. Single sting Wasps and Yellow jackets are generally: volatile in their temperment. Multiple stings
T/F: Cross sensitivity reaction will occur with Hymenoptera, ie. Allergy to bee sting=allergy to wasp, etc.	True p. 1345 - Which insect (hymenoptera) is the most potent sensitizer?	Yellow Jacket p. 1345
You suspect a toxic rxn, which appears similar to anayphylaxis- though generally more N/V/D. What general rule determines admission/observation (aside from clinical "gut instinct") -(3)	1. >100 stings 2. Those with comorbidities 2. Those in extremes of age p. 1345**	I know, Toxic reaction that seems as anaphylaxis will likely get admitted anyway- but there has to be a question.
In what time do anaphylactic rxns generally develop?	15 minutes... - generally NLT 6 hrs. p. 1345
What often will suggest the severity of the reaction following a bee sting ?	The shorter the interval between stings and the onset of sxs the more severe the reaction. - there is no connection between the number of stings the reaction of anaphylaxis. p. 1345	MC: IgE mediated. - may start as itching, flushing and dry cough. Then rapidly progress to chest and throat constriction, wheezing and death
A young patient is presented to you who was stung by a bee, 5-14 days ago on vacation. She has fever, malaise, HA, hives, lymphadenopthy, and polyarthritis.	Delayed rxn to the sting: SERUM SICKNESS p. 1345
T/F:When removing a retained bee stinger from a patient, it does not matter how is it removed- just that it is removed.	True - squeezing the venom gland is not a real concern. The muscle spasm around the site following injury would have exhausted the gland so there is no rela risk of persistent/continued envenomation. p. 1346
What is the most important agent to provide anaphylaxis patient?	epinephrine (0.3-0.5 mg IM epi, 1:1000), children 0.01mg/kg, not to exceed 0.3 mg. To avoid risk with dosing, many ED's stock 0.3 and 0.15 autoinjectors (EpiPen and EpiPen Jr) p. 1346*
What additional parenteral therapies are provided for reaction patients following hymenoptera stings (w/Epi- during their observation period to ensure no relapse)	H1 and H2 blocker Steroids- though little evidence supports as a "need". betaAgonist- prn for bronchospasm p. 1346
A women comes to the ER hyperventilating and appearing ill following ant bites on leg, sustained 10 minutes ago. She has allergies to bee stings and usually has epi-pen for that, but was afraid to use it since she wasn't sure if there was a risk. But had seen on 60 minutes where this lady died...etc. The nurse rolls her eyes and says the women's crazy. Is she?	No, there is a high risk of cross sensitivity in all Hymenoptera p. 1346- she has a legit concern, they can produce systemic toxicity
What spider occupies the larget geographic area and accounts for majority of significant envenomations?	Brown recluse (Loxosceles Reclusa) p. 1347	Generally shy, nocturnal. Prefer dark, dry locations: basements, closets and wood piles. p. 1347 violin on cephalothorax, not as reliable as six paried eyes vs eight of other spiders.
What is the most common manifestation of the brown recluse spider bite?	Mild erythematous lesion- that heals in days or weeks. Occasionally, severe local rxn, mild to severe pain several hrs after bite w/erythema, pruritis,and swelling. Hemorrhagic blisters, surrounded by blanched skin. Followed by ecchymosis in 3-4 days, then necrosis. Necrosis may progress for several weeks. p. 1347	MC painless. Venom contains hyaluronidase- major enzyme responsible for necrosis and sphingomyelinase. Damage caused MC by neutrophil activation, platelet aggregation, and thrombosis.
If systemic effects from brown recluse occur, what is the hallmark, that occurs with in 24-72 hours?	Hemolysis. p. 1347
What labs should be obtained on suspected brown recluse bite, and exhibit signs and sxs or envenomation?	- CBC - Metabolic panel - Coags p. 1347
Following a brown recluse bite, sx treatment is accomplished. Many options exist, but what is deemed as the most efficacious tx? And what is the problem with it?	1. Antivenom 2. No commercially available substance in the US. p. 1347
what spider is common misinterpreted as brown recluse, but is more easily provoked to bite than brown recluse, and prefers dark, moist environments. Bite causes little to no concern for skin necrosis.	Hobo spider p. 1347
Latrodectus (Widow spider): MC bites are where, what season and why? Habitat?	1. Hands, forearms 2. April to October 3. MC in attempt to aggressively guard her eggs/young or home/web 4. Woodpiles, basements, garages and sheds p. 1348	Venom is rich with Alpha-latrotoxin- acts on calcium depend/independ. pathways...receptor stimulation and massive release of neurotransmitters: Ach and Norepi
A young kid went to put sock on foot when he felt a pinprick and an immediate rush of local pain in foot, worst pain he ever felt...fell to the floor and immediately cried for parents. Pain was felt in foot and by the time parents at his side (seconds) rush of intense inconsolable pain throughout leg. What causes this?	Black Widow spider bite. p. 1349	Erythema MC takes 20-60 minutes...may actually have target lesion at site of bite too. MC c/o muscle cramps- rigidity (particularly the abdomen) and diaphoresis at the site. HTN, Tachycardia, HA, N/V/D. Pain may last several days.
Widow bites. What is the effective treatment for sxs, and then for the bite itself?	May clean local site. However, effective analgesia with parenteral opioids a must. Benzo's also a must for muscle relaxation. Antivenom is needed for the bite itself. IV calcium is ineffective. p. 1350
What can, and should, be provided for widow bites because it leads to rapid resolution of sxs and can significantly shorten the course of illness?	Latrodectus Antivenom p. 1350	Infact, after antivenom provided, some patients can be d/c'd from the ED w/o admission.
A 24 wk pregnant comes to the ED with c/o black widow bite. You happen to have antivenin latrodectus mactans in stock (weird), and you go to write the order. When you do the nurse comes to you and says she cannot give it because there is a contraindication for this in pregnancy?	Tell her to comply with the order and if she wishes contact the pharmacy...but there is no contraindication for pregnancy with this. p. 1351
A local warehouse worker comes to you after getting bit by "an exotic spider" while he was sorting bananas. He has not health issues and seems healthy, approx 22 yrs old. He is worried he will get sick. What do you tell him.	It was likely an "armed spider" (phoneutria) - while neurotoxic venom, MC in healthy individuals, may cause severe pain- which resolves in 1-2 days. For severe cases: Antivenom is available. p. 1351
You have a patient who was bit by the armed spider. Rxn appears severe, you have antivenom and provide it. What medication at this point should not be used (in general)	Opioid analgesia... - these cause respiratory depression, which is already a grave risk for these patients (contraindication) p. 1351*
What spider, native to Australia, burrows into the ground, shiny black bodies w/large fangs, generally stay by their burrow (females), but have been known to be aggresive (males) and wonder from the barrow-particurly in the summer and possess a venom that is a mixture: Neurotoxic with Neuromotor and Autonomic effects?	Funnel Web Spiders p. 1351
What bite, which in most cases does not cause systemic effects, causing a painful local reaction, wheal, with local sweating and piloerection- similar to black widow spider?	Funnel Web spider p. 1351
A patient is brought to you, an international traveler returning from Australia, with an impressive erythematous eruption on his right thigh. Who recently c/o perioral numbness, N/V/D, diaphoresis, tremors, coughing and frequent spitting, with AMS, just prior to going into cardiac arrest. What should be done?	Naturally, you will work the cardiac arrest...tho it rarely gets to that point. 1. if you caught this when the eruption first begun, you would have wrapped the leg with compressive bandage. 2. prior to cardiac arrest, with the systemic sxs, you would have given: Funnel Web spider antivenom. (2 ampules q 15 minutes until sxs improve, MC at least 4) p. 1351*
What is the only tx known to improve survival in patients who suffer funnel web spider bites?	Antivenom P. 1351*
What is the tx of localized extremity bite from funnel web spider bites?	Compressive elastic bandage should be applied to the entire extremity and the extremity splinted, to prevent systemic absorption. p. 1351*
A teenager is presented to ED following sudden eye redness and irritation. States that he had leave work early from his job at the pet store where he is responsible for tending the Tarantulas. States that his vision is blurred from irritation and pain. What's is the likely reason, w/o any additional eye hx (no surgeries, no direct trauma).	Imbedded trantula hair. Any patient who has red eye and pain and has hx of handling tarantulas, should be examind to determine if offending barbs are present in cornea or conjunctiva. Call ophtho- this can be very serious p. 1351*	He likely startled it, and it flicked it's hairs into his eyes. - Call optho. This can be from corena/conjunctiva clear back to retina.
What type and venom effect is there with a wolf spider?	Cytotoxic- with local effects, none systemic. p. 1351
What is the only scorpion in the states capable of causing systemic sxs?	Bark Scoprion. p. 1352	Effect is on sodium channels...causing excessive depolarization. - not common in general, but MC severe in children
If death occurs following scoprion sting, what from?	Cardiogenic shock or pulmonary edema p. 1352	roving eyes, pharyngeal spasms, incoordination, drooling, respiratory compromise. Restless and seizure activity. W/o antivenom...sxs last 24-48 hrs.
Scoprion sting tx?	Supportive generally: analgesia, benzo's. Atropine, for excessive secretion as well hypersalivation and resp distress...but contraindicated when not stateside. Antivenom has been shown to reduce/eliminate systemic sxs in 4 hrs. p. 1352
A patient is presented to you following a camping trip in the mountains, he has symmetric ascending paralysis and loss of deep tendon reflexes. What is the vector? What do you do?	a. Tick, this is tick paralysis. b. Entire body examination, all hair, looking for engorged tick. (if no tick, possible guillain-barre) p. 1352*	* prompt removal is imperative, as the transmission of dz is time dependent.
Chiggers, how do u tx?	You don;t have to. Nothing comes of it. However, if you wish: antihistamines, topical steroids, and rarely systemic steroids...if aggressive. Permethrin will kill them too. p. 1352
T/F: No concerns with misquito bites, they are just pests. Tx is topical steroids rarely, antihistamines...resolve in days.	False: - malaria - japanese B encephalitis - yellow fever - dengue fever - equine encephalitis... Risks just to name a few p. 1353
What vector causes Chagas Dz?	Kissing Bug, Cimicidae p. 1353	- Chagas Dz (parasite: Trypanosomiasis) in central and south america
What two bugs are nocturnal, usually intend to bite warm bodies, humans. Their bite is painless, but can still cause disease?	1. bed bugs (Reduviidae) 2. Kissing bug (Cimicidae) p. 1353	How can you tell a part? Patient examine bed sheets, excrement is left by bedbugs. Kissing bugs do not bite in linear pattern.
MC local reactions are caused by catepillars or moths? How? And how can you easly fix it?	1. Catepillars 2. The hairs or spines on them 3. Using tape, remove the spines. Otherwise sx tx. But the spines/hairs need to be removed. p. 1353
How are blister beetles best removed from the skin?	Blow or flicking off p. 1353** - they have a vesicant venom which is exuded from their joints when disturbed or from their body when crushed.
Why are crotaline snakes call "pit vipers"?	Because of the depression on their face between their nostril and their eye. p. 1354	Also, they can be characterized by their fangs that fold to the roof of their mouth. Unlike coral which are shorter and fixed
T/F: Rattlesnakes will MC rattle a warning prior to a strike.	False - often this does not occur. p. 1354
FYI...not a question- next slide.	Crotaline venom is a complex mixture, that causes: local tissue damage, hemolysis, fibrinolysis (in fact, the venom quickly activates to consume fibrinogen and platelets), neuromuscular dysfunction- which results in local and systemic effects. p. 1354	Venom quickly alters blood vessel permeability which leads to loss of plasma and blood to surrounding tissues, causing hypovolemia.
What are the "cardinal signs" of a crotaline venom poisoning?	1. presence of one or more fang marks 2. localized pain 3. progressive edema, extending from the bite site.	25% of bites are dry. Otherearly signs/sxs: - N/V - weakness - oral numbness or tingling of the tongue/mouth - dizziness - muscle fasciculations
Dx of snake bite is dependent on presence of fang marks and hx c/w exposure. Snake envenomation depends on?	Presence of snake bite as well as evidence of tissue injury. Clinically this is manifested in what three ways? (next card, this is important cause both questions are bolded)	1. local injury: swelling, pain, ecchymosis 2. Hematologic abnormality: thrombocytopenia, elevated PT, hypofibrinogenemia 3. systemic effects: oral swelling or paresthesia, metallic or rubbery taste in mouth, HoTn and tachycardia. p. 1354*
A patient has been observed for 8-12 hours following a snake bite and has not revealed systemic, hematologic or advancing/worsening localized sxs. What does this mean?	Dry bite. p. 1354
What should first aid treatment of pit viper but NEVER include?	suction and incision and draininage of the bite site p. 1355*	Electric shock treatment- should not be used, can cause electrical injuries. Ice water immersion- worsens injury
Why are tourniquets contraindicated in the treatment of pit viper bites?	They obstruct arterial flow and cause ischemia. However, constriction bands can be useful when medical care will be delayed. p. 1355*
Constriction bands, elastic or penrose drain, prevent peripheral venous return, but peripheral pulses remain. What is the general rule with regard to it's "tension"/application?	The band should be snug, but loose enough that a finger can slide confortably underneath p. 1355*
What is the mainstay of therapy for poisonous venom bites by snakes?	Antivenom, such as crofab (CROtaline polyvalent immune FAB, CROFAB). p. 1355*	Remeber Dr Vic B's lecture, 6 vials, rolled, not shaken to start, then again until control of sxs...then 2 vials every 6 hrs there after x 3. Comes from sheep (I was actually asked this as a pimp question...no B.S.)
All patients with progressive signs and sxs from a snake bite should receive the antivenom. Define progression of sxs.	A worsening of local injury (pain, ecchymosis, or swelling), abnormal results on laboratory tests (worsening platelet counts, prolonged bleeding times, decreased fibrinogen levels), or systemic manifestations (unstable vital signs or abnormal mental status). p. 1355** (see also, Table 206-3)
How are children treated following a snake bite?	The total volume may be reduced, but not the total vials. p. 1356*
How can one tell of the effected extremity following a snake bite is advancing?	Limb circumference should be measured at several sites above and below the bite, every 30 minutes. p, 1356
Hematologic abnormalities are evident in your patient following their snake bite, and you administer antivenom. But active bleeding starts. What is done next?	Blood component replacement is now a must. p. 1356*
Management of compartment syndrome after crotaline bite is very difficult. What do you do?	Recognize: severe pain, localized to compartment, not controlled with opioids. 1. Determine the compartment pressure (not elevated, continue conservative measures) 2. If signs of compartment pressures are elevated, > 30 a. elevate limb b. Administer mannitol 1-2 gm/kg IV over 30 minutes. While administering additional FabAV, 4-6 vials IV over 60 minutes c. If elevated compartment pressures persist for more than 60 minutes, consider fasciotomy. p. 1356, Table 206-4*
How long should a patient be observed for, if uncertain, before determining the disposition after a pit viper (crotalid) snake bite?	8 hours p. 1356*
T/F: There is an absolute rule about the following, regarding coral (elapids) snakes: "Red on Yellow kill a fellow, red on black venom lack".	False, when not in the US... p. 1356* Nxt slide	Venom is predominantly NeuroToxic and does not generally cause a local injury
What should be done with a patient, who appears well, but comes to you following a coral snake bite?	Admit to the hospital for admission. The neurotoxic effects may be delayed. 3-5 vials of antivenom for those definately bit, the effects may not be prevented or reversed once they develop. p. 1356	- admit to ICU. Respiratory failure may occur, serial measurements of pulmonary function a must
What are the neurotoxic manifestations most commonly found in elapid snakes in the world?	tremors, salivation, dysarthria, diplopia, bulbar paralysis- w/ptosis, fixed and constricted pupils, dysphagia, dyspnea, and seizures. With the immediate cause of death being respiratory arrest. But sxs may be delayed by 12 hrs. p. 1357	The injection of their venom is voluntary
What is the first aid treatment of elapid snake bites?	Same as for pit vipers, pressure bandage around entire extremity, followed by immobilizer application. DO NOT apply tourniquet. Just prevent lymphatic spread p. 1357*	Read p. 1357: Pathophys, clincal features, and Dx. It is interesting and no easy way to make a question.
You have a patient in the ER, following a coral snake bite. You have IV access and the patient appears OK, with an elastic wrap and splint around his right arm. Labs are well, patient again is OK. You loosen the wrap and the patient rapidly deteriorates. What do you do?	Reapply the elastic wrap and provide antivenom and then re-remove the wrap to allow antivenom to penetrate the site. Antivenom should generally only be given to the case with clear, clinical or lab evidence of envenomation. p. 1357*	If he had no rxn, then he would need to be observed for 12 hrs for no development of rxn
What is the percentage of cobra bites that are dry? And what are the two different ways a cobra will deliver venom?	- 45% are dry - bite and spitting jets of venom. p. 1358
What type of venom is possessed by the cobra snake?	1. neurotoxin is the acutely concerning venom to patients health 2. necrosis producing toxin is typical of spitting cobra snakes. p. 1358	- Neurotoxin MC binds to postsynaptic Ach receptors
T/F: The only first aid measure proven of any use is eye irrigation, when spit with venom by spitting cobra.	True. All other first aid measures have not been proven any benefit p. 1358
What is the only proven therapy and treatment for cobra envenomation?	Antivenom p. 1358- however, the purity and source are variable, so be very prepared for allergic reaction
You do not have antivenom for cobra venom available. However, the patient is presented to you w/paralysis. Is there a drug that may help?	Cholinesterase inhibitor, such as Edrophonium - until antivenom is available. p. 1358
Gila monsters have venom as strong as rattle snakes, but smaller teeth instead of fangs. What do they depend on to deliver their venom?	Prolonged bite p. 1358- the tenaciousness of their bite often will also provoke tendon injury and fx	-place the animal on a soft surface, it is more likely to let go when not suspended in air.
What is are the three likely reasons for death following a shark bite?	1. prehospital resuscitation 2. hemorrhagic shock 3. drowning p. 1359	Sharks are more likely to bite the appendages of their victims: people/seals, etc.
What are the two "major" concerns regarding shark injuries?	1. massive tissue injury with hemorrhagic shock 2. an extremely high incidence of contamination w/atypical microorganisms that produce wound infections p. 1359	However, shark related deaths have dropped by > 40% 2/2 the increased training of first responders as well as the insight into abx use
Why are x-rays taken of shark bite sites?	- to visualize fx's, periosteal stripping, and determine of FB's are retained. p. 1359
T/F: Prophylactic abx's are recommended for all shark bite injuries.	True! p. 1359*	Organisms: Vibrio, Staph and Step
What is the tx for barracuda, moray eels, piranhas, sea lions, etc.?	Similar to treat for shark bites, with the emphasis on irrigating the wounds, removing foreign bodies such as teeth and spines, and leaving puncture wounds open to allow adequate wound drainage. p. 1359*
What is the most common injury sustained underwater; usually being sustained hands, forearms, elbows, and knees?	Coral Cuts p. 1359
What is coral poisoning?	sxs c/w: systemic malaise, fever, diarrhea, and general exhaustion associated with a wound from coral cuts/injuries. p. 1359	Wounds should be irrigated extensively, with strict wound cleaning responsibility following cuts.
The majority of infections from marine associated wounds are from what?	Skin flora: S.Aureus, S. Epidermidis, Step and certain bacilli. p. 1359 - What is the MC marine species associated w/infx?	Vibrio species... P. 1359
What is the priority for the management of infections from marine micro-organisms?	The recognition that they are often more serious than other common soft tissue infections. p. 1360* - appropriate cx techniques should be in employed. This is important, as particular culture media is needed to identify this-call the lab	Emperic abx tx? Many wounds are polymicrobial and the tx option should reflect this...
No abxs, prophylactic abx, or hospital admission/IV abx. Healthy pt, prompt wound mgt, no FB, no bone bone/joint involvement, small or superficial injury.	No abx tx needed. p. 1360, Table 207-1
No abxs, prophylactic abx, or hospital admission/IV abx. Late wound care, large lacerations/injuries, early or local inflammation.	Prophylactic/Outpatient Abxs p. 1360, Table 207-1
No abxs, prophylactic abx, or hospital admission/IV abx. Predisposing medical conditions, long delays before definitive mgt, deep wounds/significant trauma, wounds with retained FB, progressive inflammatory changes, penetration of periosteum/joint space/body cavitiy, majory injuries with envenomation, systemic illness.	Hospital Admission for IV abxs p. 1360, Table 207-1
While abx coverage for strep/staph species is a must. However, one also has to protect against what species in sea water? And to protect against this, what will you use? What about freshwater?	1. Vibrio species 2. Third generation cephalosporins or fluoroquinolones 3. Aeromonas Hydrophilia, fluoroquinolone, bactrim, third generation cephalosporin or imipenem p. 1360
What presentes as a sharply marginated, painful, expanding plaques on the fingers or hands following cutaneous innoculation?	"fish handler's disease", E. Rhusiopathiae p. 1360	- it is sensitive to PCN, fluoroquinolone, and cephalosporins
Mycobacterium marinum, what is the tx?	Clarithromycin and ethambutol or rifampin p. 1360
Marine toxins, there are 4 different types. What are they?	1. neurotoxic 2. hematoxic 3. cytotoxic 4. myotoxic p. 1360
What has been shown to inhibit nematocyst discharge in Lytocarpusphillippinus?	Vinegar p. 1360*- however, the utility in other species of hydrodozoa, invertebrate envenomations has not been determined.	However, this is not the treatment for sxs: pain with analgesia, itching with antihistamines, etc.
A teen in the tropics was in the shallow waters picking up seaweed when he developed an immediate burning, stinging pain, radiating proximally. Occurred an hour ago, you see wheals and papiles. What is the source and tx?	1. Millepora (hydrozoa) 2. Sx tx- will MC resolve/improve 1-2 hours after the injury p. 1360
How long can the nematocysts remain active from fractured tentacles, protuguese man of war?	Months p. 1360
T/F: Phalasia envenomation can lead to death via respiratory depression.	True p. 1360-1361 delayed effects have been reported though	ex of phalasia, Portuguese Man of war.
What are schphozoa?	"True Jelly fish" p. 1361	CUT THE CRAP! Stop complaining. I know the question sucks. But ask yourself, are the jerks writing our tests capable of this? I accept your apology!
T/F: Severe stings, with potentially fatal reactions are common in "true jelly fish" stings.	False... - though stings are common, there are very few reports of severe reactions. p. 1361
What marine creature is believed to cause deaths, MC in children, from a cardiotoxic role within 20 minutes of exposure?	Cuboza, Indo-Pacific Box Jelly fish - p. 1361
Carukia Barnesi, a Carybdidae, marine creature is responsive for sxs: mild local pain and irritation at the site of the sting, that with in 30 minutes progresses to systemic sxs: abdominal pain, back, chest, head, and limbs. Tachycardia, HTN, sweating, piloerection, agitation. Sometimes Pulm edema as well as cardiac depression. This is a syndrome, what is it called?	Irukandji Syndrome p. 1362
Following a jellyfish sting, how long should the patient be observed? Why?	1. 8 hrs 2. because of the risk for ongoing envenomation or delayed reactions p. 1362
What is primary first aid for jelly fish stings?	Deactivation of the nematocysts. p. 1362
You are walking on the beach, when you notice an individual pulled from the water stung by a jellyfish. You, remembering how awesome you are thanks to your highly educational residency, that the primary tx for this injury is deactivation of the nematocysts. You run over to the patient preparing to take the Dasani water you're drinking on the patients wounds, when a life guard stops you. Why is the life guard right?	Freshwater rinsing is not recommended, because this hypotonic solution is thought to stimulate nematocyst disharge. p. 1362*	- after decontamination, visible tentacles can be removed.
What is the treatment of choice, to deactivate nematocysts?	5% acetic acid, vinegar p. 1362*
A persons is stung by a jellyfish and calls for your "I need treatment cause I got stung by a jellyfish, but hoping your advice will help instead" hotline. Cold or heat application?	Heat- it is believed to reduce the toxicity associate with the sting. - constant flow of warm/hot water= + results. p. 1362
What, as a general rule, are the only two marine (jelly fish or like) stings that will lead to "severe systemic" effects?	1. Physalia 2. Box jellyfish p. 1362*
What jellyfish sting tx consists of antivenom?	Chironex p. 1362
T/F: Jellyfish sting work up include: EKG, Troponin I, and sometimes echocardiogram.	True p. 1362
What is stinging sponge dermatitis?	A dermatic skin eruption, dermatitis, caused by sponges. Often delayed by a few minutes or hours and often painless on contact. Increases in intensity over 2-3 days. MC runs course and needs sx treatment. p. 1362
A persons is has horrible irritation on hands and calls your "I need treatment cause I got injured by a sponge, but hoping your advice will help instead" hotline. Cold or heat application?	Cold application. The area should be irrigated, but unlike jellyfish that benefit from heat application. Sponges benefit most from cold. p. 1362
T/F: Sea urchins, along with causing a risk of local irritation from penetration of site, as well as synovitis when penetrating the joint capsule, is also responsible for a significant amount of systemic sxs and death.	False - systemic sxs and death is rare p. 1363
What is the first aid tx for echinoderm (sea urchins, sea cucumbers, and star fish)?	Immediate immersion in hot water to tolerance (45 degrees C (113 degrees F) for 30-90 minutes or shorter if pain is relieved. p. 1363**
The phylum mollusca contain 2 creatures. What are they?	1. gastropods (cone snail) 2. cephalopods Octopus p. 1363	1. cone snail MC stings are rare. However, if occurs it is after prolonged exposure to shell or after interfering with the creature, ie breaking the shell 2. MC local irritation. However, severe cases= paresthesias and paralysis; respiratory depression.
Sting from this creature may cause: partial paralysis, muscle paralysis respiratory failure?	Cone snail... - no specific tx. Supportive. p; 1363
T/F: it is common for the stingrays spine to remain in the wound site, and are discovered on x-rays.	False, it is uncommon for the spine to break and remain in in the tissue. (though it does make sense that it would show on x-ray) p. 1364
What is the significance of the following fish: catfish, stonefish, weeverfish, scorpionfish and lionfish?	Venomous fish stings p. 1365
WHat is the MC reason for necrotic change in stonefish injury?	secondary infection. Truth is the is exceedingly rare. THis is MC local issue that resolves. p. 1365
The systemic effects, such as syncope, related to scorpionfish, rockfish, and stonefish stings are from what?	MC this is only going to occur 2/2 to the patients response to pain more than from "toxin effects". p. 1365
What saltwaterfish is the most venomous fish in the temperate zone: mediterranean and european regions, whose spine can penetrate a leather boot. Is a bottom dweller, and the injury caused by this is prone to necrosis.	Weever Fish p. 1366
What is the successful therapy for venomous fish and sting ray stings?	Requires the treatment of the traumatic injury and the envenomation. Treatment is directed at: 1. reversing the effects of venom 2. alleviating pain 3. preventing infection p. 1366*	- the wound should be aggressively irrigated and visible debri removed (like you didn't see that coming!) - control bleeding - hot water immersion (as tolerated, 30-90 minutes ideal) - no relief with immersion? consider analgesia and/or local anesthesia w/o epi.
How should the lacerations caused by sting rays be treated?	Lacerations caused by sting rays should be left open for delayed primary closure; or sutured loosely to permit adequate drainage. p. 1366*
What is proven most effective route of administration for antivenom following stonefish envenomation, IV or IM?	IV (though both are acceptable) p. 1366
What percent of sea snake cause significant envenomation? What percent are then potentially fatal w/o treatment?	1. 20% are significant envenomation 2. 40% are fatal w/o tx p. 1366 Venom contains neurotoxins and myotoxins. None effect coagulation.
T/F: Sea snake bites are initially painful and progress in exquisite intensity over 30 minutes.	False, - these are usually painless and progress in sxs over 30 minutes p. 1367
A patient is brought to you 4 hours after swimming in the ocean, he has since had nausea, muscle aches: neck, face and trunk...increasing in intensity to trismus. What is it?What is the treatment?	1. Sea snake bite 2. Immobilze effected extremity, supportive tx and then antivenom. p. 1367
You suspect that a patient has sustained a sea snake bite and are concerned that the patient may suffer neurotoxic effects. How long should they be observed for?	6-8 hrs. If no effects in that time, no need to worry p.1367
When does a patient receive polyvalent sea snake antivenom?	When there is evidence of systemic envenomation. p. 1367
What do the following conditions have in common: barotitis (ear squeeze), sinus barotrauma, inner ear barotrauma, and face, tooth, or dry-suit squeeze.	Barotrauma of descent p. 1367
What happens to the volume of gas in "air containing" body cavities, when the body descends?	Decreases p. 1367
What is the condition that occurs when the ostia to the sinuses are occluded, air cannot enter the sinuses during descent to equalize the increasing pressure. This causes pain and mucosal edema and can lead to submucosal hemorrhage and stripping of the sinus mucosa from bone,hemorrhage, and rarely, paresthesias in the infraorbital nerve distribution?	Sinus Barotrauma p. 1368
What can happen to a diver when they attempt to valsalva against an occluded eustachian tube?	- rupture of the oval window - fistulization of the window - tearing of the vestibular membrane - or a combination of such injuries... p. 1368 WHAT SXS MIGHT THEY HAVE?	unilateral roaring tinnitus, sensorineural hearing loss, and profound vertigo.
What is a fistula test, for inner ear barotrauma?	Insufflation of a tympanic membrane, of the effected ear, causes the eyes to deviate to the contralateral ear p. 1368
What happens to the air inside of a body cavity as it ascends?	It expands p. 1368
If an individual was diving and attempts to ascend, following a panick attack, what could happen, ie what is it called?	Pulmonary overinflation or burst lung syndrome - air expands...could rupture the lungs. This could lead to a pneumomediastinum p. 1369
What is CAGE? What is the "most sensitive" risk for this?	Cerebral Artery Gas Embolism. Cerebral embolization. -p. 1369
What should you be thinging of when an individual has neurologic signs/sxs referable to the circulation to the central nervous system in the setting of barotrauma?	CAGE - cerebral arterial gas embolism. p. 1369
What is the type of decompression sickness for the following: Deep pain in the joints and extremities, unrelieved but not worsened with movement (MC single joint: knee/shoulders). Skin changes-mottling, puritis (lymphatic obstruction can occur) color changes.	Type 1: pain only decompression sickness p. 1369 Table 208-2
What is the type of decompression sickness for the following: "pulmonary (chokes)- cough hemoptysis, dyspnea, substernal CP. Cardiovascular collapse, Neuro sensation- ascending paralysis", vestibular staggers- vertigo, hearing loss, tinnitus, and dysequalibrium (MC with deep, long dives)?	Type 2: serious decompression sickness p. 1369 Table 208-2
What is the type of decompression sickness for the following: sxs of DCSII as well as syndromes c/w stroke sxs. Sxs occur on ascent or immediately upon surfacing. May spontaenously resolve.	Type 3: combination DCS and AGE p. 1369 Table 208-2
MC the sxs of decompression sickness occur "how long" after surfacing?	minutes to several hours. Rare, but ther have been sxs occuring as late as "days" after diving have been reported. p. 1370*
Why is an "accurate dx of decompression sickness often difficult" in Type I DCS?	It is often difficult 2/2 the pain in the joints and extremities that is not worsened with movement or relieved with rest. Often believed to be associated with an injury. p. 1370	- it is believed that the "bubbles" from the joints extend into the fascia and ligaments.
What does poorly localized back or abdominal pain in diver, suspected of having DCS' suggest?	Serious signs of spinal cord DCS p. 1370
You are evaluating a diver who c/o sxs c/w: " a girdle restriction across his chest", Wooly sensation in feet, and sensation or paralysis moving up his feet and legs. Occurring very rapidly. What is happening with this guy?	type 2 decompression sickness... MC affects lower cervical and thoracic regions... p. 1370
A patient ascends after diving, shortly after surfacing the patient develops sxs of unconsciousness, after complaining of sxs of "blindness, right side paralysis, as well as an observed period of disorientation, then developing a seizure...what happened to this poor guy?	CAGE (Cerebral Arterial Gas Embolism) p. 1370
What is the treatment for CAGE as well as DCS?	Administration of 100% oxygen, increasing tissue perfusion with IV fluids, and rapid recompression. p. 1370
What, according to this particular chapter of Tintinalli's, is the preferred position of recovery for CAGE...Trendelenburg or Supine (flat)?	Supine... p. 1370 - however, e18.1- suggests lateral recumbent or trendelenburg	lateral recumbent if emesis
Diver dives to 200 feet, and develops sxs c/w EtOH intoxication and begins to make foolish decisions, almost jeopardizing those with him. You learn of this from his friend who had to see him get eaten by a great white he oddly tried to play with. What happened to this poor guy?	Nitrogen Narcosis p. 1371
Patient was novice scuba diver and used just some O2 tanks that he rigged up, that had a continuous delivery of oxygen, was diving w/o recent illness and no hx of seizures, but at only 25 feet, develops a seizure and subsequently drowns. Why is the likely reason?	Oxygen toxicity p. 1371
What effects do the following w/major burns have on patients: larger burn size, older age, the presence of injury and female sex?	Increases the risk of death p. 1374
What are the physiologic effects of thermal burns?	1. disruption of the sodium pump 2. depression of myocardial contractility (>60% BSA burned) 3. Increased systemic vascular resistance 4. Metabolic Acidosis 5. Increase in HCT and blood viscosity 6. Secondary Anemia- from erythrocyte extravasation and destruction 7. Local tissue injury p. 1374
What are the 6 most important factors influencing prognosis in burns?	1. severity of the burn 2. the presence of inhalation injury 3. associated injuries 4. the patient's age 5. pre-existing disease 6. acute organ system failure. p. 1375**
What are the three zones of burn injury.	1. zone of coagulation (tissue is irreversibly destroyed with the thrombosis of blood vessels) 2. zone of stasis (stagnation of microcirculation) 3. zone of hyperemia, increased blood flow p. 1375
What is the rule of nines?	It is a means to calculate the BSA of a surface burned utlizing multiples of nine p. 1375*
When determining the body surface area burned for a patient...the area that is the back of a patients hand is how much of their body surface area?	1% of the body surface is approximately the size of the back of the hand...it can be used to approximate the percentage of the BSA burned. p. 1375*
What is a "more precise" means of determining the body surface area burned?	Lund and Browder Diagram p. 1375
What are the different layers of burn depth?	1. Superficial burns 2. Superficial-partial thickness burns 3. deep-partial thickness burns 4. full-thickness burns p. 1375
What is a burn that causes the skin to be red, painful, tender, w/o blister formation?	Superficial burn p. 1375*	MC heals in 7 days w/o scarring. Sx tx only.
What is the MC cause of superficial partial thickness burns?	Hot water p. 1375
What type of burn develops blisters and is red, moist at the blister base?	Superficial, partial thickness burns. p. 1376*	superficial, partial thickness burns. heal w/in 14-21 days, minimal scarring
What are some common causes of deep, partial thickness burns?	hot liquids, steam, grease, flames p. 1376
What burn is MC: blistered, and the exposed dermis is pale white to yellow in color. The burned area does not blanch; it has absent capillary refill and absent pain sensation.	Deep partial thickness burn. p. 1376*	3 weeks to distinguish from full thickness burns. Healing takes three weeks to 2 months
What burn involves the entire thickness of the skin. The skin is "charred, pale, painless, and leathery".	Full thickness burns. p. 1376
What burns are those that extend through the skin to the subcutaneous fat, muscle and even bone.	Fourth degree burns p. 1376*
What age range defines a high risk age group, with regard to burns?	< 10 and > 50 yrs old. p. 1376	LOOK AT Table 210-3, "BURN DEPTH FEATURES: AMERICAN BURN ASSOC BURN CLASSIFICATION, Table 210-4...this is the list of "REFERRAL CRITERIA"
What is the main cause of mortality in burn patients?	Inhalation injury p. 1377	Since efforts have improved the treatment of burn shock as well as sepsis FYI: MC, burns are to the upper airway. Airway injury below the vocal cords MC is in the presence of steam
What are the two major tissue asphyxiants (of toxic inhalants)?	1. Carbon monoxide 2. Hydrogen Cyanide p. 1377
What should be done with those burn patients suspected of being exposed to carbon monoxide?	100% oxygen by non-rebreather and evaluation consideration of hyperbaric mgt p. 1377
Early institution of hemodynamic monitoring is recommended for those who sustain in halation injury. Why?	Fluid resuscitaion must be done carefully, to avoid: 1. pulmonary edema 2. Acute respiratory distress syndrome p. 1377
What are the 6 "basis" of prehospital care for burn patients?	1. stop the burning 2. est the airway 3. initiate fluid resuscitation 4. relieve pain 5. protect the burn wound 6. transport the patient to the appropriate facility p. 1378
Why should all jewelry: rings, watches, and belts be removed from the burn patient?	they retain heat and produce a tourniquet effect on the extremity, which causes ischemia. p. 1378
Why is diligent attention to the airway of a burn patient a gross imperative?	Rapid swelling may occur even when the initial assessment judges the airway acceptable. p. 1378*
Early cooling can reduce the depth of burn and reduce pain. What are the risks?	Uncontrolled cooling can result in hypothermia. p. 1378
When should endotracheal intubation be performed in burn patient?	1. evidence of airway compromise w/swelling of the neck 2. burns inside the mouth, wheezing... additional evidence to consider: examine for signs of inhalation injury, singed nasal hair, facial burn and soot in mouth. p. 1378
WHat labs should be drawn on a burn patient who sustains an inhalation injury?	- ABG - Carboxyhemaglobin level - CXR - ECG p. 1378
What is the treatment of suspected inhalation injury?	- humidified 100% O2 - intubation and ventilation - bronchodilators - pulmonary toilet - hyperbaric oxygen for carbonmonoxide poisoining p. 1378
T/F: The parkland formula is the most appropriate resuscitation formula and yields the most positive outcomes.	False: the formulas serve as a guide for fluid resuscitation, which must be monitored and adjusted according to the patient response. In spite of the BS handed to you by those in leadership, there is NO better way. University uses the Brookes formula. It actually is simple enough... p. 1379
T/F: Prophylactic abx management using PCN or Cephalosporin is appropriate for burn mgt.	False- prophylactic abx mgt is not necessary or appropriate for burn patients. p. 1379	Td prophylaxis is appropiate. Also, consider the use of Tetanus Immunoglobulin
Often, clean, dry dressings are appropriate initially in the treatment of burns. However, prior to transfer, cool, moist saline soaked gauze can be helpful. Why?	1. cooling affect often causes localized vasoconstriction 2. cooling stabilizes mast cells and reduces histamine release, kinin formation, and thromboxane B2 production - However! for large burns, sterile drapes are appropriate 2/2 risk of hypothermia. p. 1379
T/F: circumferential, deep burns to the upper extremities are at a high risk for the development of compromise of peripheral circulation, so distal pulses should be monitored regularly.	True p. 1379 - Doppler testing is very useful, if needed. However, this needs to be performed.
Adequate analgesia is a must in the tx of burns. Why is IV mgt the most appropriate?	PO and muscle absorption is unreliable 2/2 to decreased perfusion. p. 1380
What type of burn would "briefly describe the following"? - isolated burn - should not involve the hands, feet, or perineum. - burn should not be circumferential.	Minor Burn p. 1380*
T/F: A burn patient who is elderly or with comorbid conditions, even if burn is < 10 % of BSA should be managed inpatient.	True p. 1380*	When a minor burn is treated, the patient's social and medical situation should be considered.
What allergy and location of application is a contraindication for the use of sulfadiazine?	1. Sulfa Allergy is a "no, no" 2. DO NOT ever apply this to the face- it can cause staining p. 1380
How often are burn dressings changed, as long as wounds appropriately weep?	twice daily p. 1380
WHat is the premise behind the use of synthetic occlusive dressing applied to wounds?	Acts as the protective skin. This is great, because it blocks the bacterial activity, which possess fibrinolytic enzymes- which prohibit adequate wound healing. p. 1380
T/F: There are clear discernable differences in non-poisonous and poisonous mushrooms.	False, there are no recognizable differences in these...the best thing to do, just don't eat wild mushrooms. Toxins have a not sensitive to heat, and can tolerate canning, freezing, drying or other means of prep. p. 1394
What is the prognosis of the patient who ingests mushrooms and develops sxs w/in 2 hrs? What about the patient who developed sxs in > 6 hrs?	- 2 hrs- better prognosis - 6+ hrs- poor prognosis (more serious, potentially fatal) p. 1394*	Nearly all fatalities stem from the Amanita species...though tx is guided toward identification of the patients sxs more than the shroom...
T/F: sxs of mushroom ingestion are poorly described. Often do not present to the ER. MC c/o: V/D, cramps, chills, HA, myalgias and Diarrhea- which MC is watery, but can be bloody. Sxs MC resolve w/in 24 hrs.	True p. 1394
What is the general tx for toxic mushroom ingestion?	Activated charcoal 0.5-1.0 gm/kg, PO or by Nasogastric tube. Additionally, supportive and includes IV fluid as well as electrolyte replacement. Antiemetics +, Antidiarrheals negative. p. 1395
T/F: THe chemical in hallucinogenic mushrooms is the same as LSD?	True, the chemical is psilocybin p. 1396
When do sxs MC develop following mushroom ingestion?	Within 2 hours p. 1396*	Sxs MC last 4-6 hrs, but can persist for 12. There are some reports of individuals experiencing flashbacks 4 months after.
Patients who ingest ISOXAZOLE-CONTAINING mushrooms usually present with sxs w/in what time?	w/in 30 minutes p. 1396*	Sxs are: dizziness, mild intoxication, ataxia, muscular jerking, difficulty with perception of size, time and place are common
What are the characteristics/sxs of a muscarinic overdose?	SLUDGE syndrome: Salivation, Lacrimation, Urination, Defecation, GI hypermobility, and Emesis. p. 1396
The muscarinic sxs caused by mushrooms, SLUDGE sxs, can also develop diaphoresis, muscle fasciculations, miosis, bradycardia, and bronchorrhea...occur within what time, resolving by what time?	Occur w/in 30 minutes Resolve w/in 4-12 hours. p. 1396*
The muscarinic sxs caused by mushrooms, SLUDGE sxs, can also develop diaphoresis, muscle fasciculations, miosis, bradycardia, and bronchorrhea...occur within what time, resolving by what time?	Occur w/in 30 minutes Resolve w/in 4-12 hours. p. 1396*
What is the treatment for mushroom induced muscarinic sxs?	- Supportive sxs - Atropine- can be provided to patients, as an antidote. It can be effective in the treatment treating those who have bradycardia and HoTn, not responsive to fluids. p. 1397	Atropine: 0.5-1.0 mg adults and Atropine: 0.001mg/kg in peds
What is the treatment for mushroom induced muscarinic sxs?	- Supportive sxs - Atropine- can be provided to patients, as an antidote. It can be effective in the treatment treating those who have bradycardia and HoTn, not responsive to fluids. p. 1397	Atropine: 0.5-1.0 mg adults and Atropine: 0.001mg/kg in peds
Mushroom toxicity: What has the greatest effect on the cells that undergo rapid protein synthesis and turnover, including cells of the GI tract mucosa, hepatocytes, and renal tubular epithelium.	Amanitine p. 1397*
What possess substance/mushroom toxicity, has "distinctive" characteristics of GI sxs: N/V and watery diarrhea, developing 6-24 hrs after ingestion, most typically between 6-8 hrs after ingestion.	gyromitrin-containing mushroom p. 1397*
What happens to patients who ingest amatoxin-containing mushrooms, early?	early GI findings at 6-24 hrs: Delayed onset of GI sxs The later the onset of the GI sxs, the milder Dz. p. 1397
How many stages are there in amatoxin poisoning?	4 p. 1397*	1. First, is the latent stage- absence of signs/sxs lasting up to 24 hrs 2. Second stage, (12-24 hrs), GI sxs: intense cramping abd pain, N/V/D 3. Third stage, the patient looks and feels better, however, liver enzymes continue to rise 4. Fourth stage, begins 2-4 days after ingestion, liver enzymes rise dramatically until liver and renal failure.
What is one of the most common causes of death in early mushroom toxicity?	Hypoglycemia p. 1398*
How long should a patient who ingested gyromitrin or amatoxin-toxicity be observed for?	48 hrs - Why? Development for hepatic and renal failure p. 1398*	- electrolyte levels - liver enzyme levels - prothrombin time these should be monitored several times per day prolonged coag times: FFP and Vit K should be considered
What are the neurologic sxs associated with gyromitrin treated with?	Pyridoxine p. 1398*	This produces the cofactor required to generate GABA, doses 25 mg/kg IV...up to 25 gm/d.
A patient consumes mushrooms, then after 3-20 days develops lumbar flank pain and oliguria...what is happening?	Renal Failure p. 1398*
What are the MC reported sxs of plant toxicity? (2)	1. Dermatitis 2. GI irritation p. 1398
How are most (toxic) plant exposures treated?	- MC these do not require any specific tx - If tx is needed, simple GI decontamination is often all that is needed. MC activated charcoal. Cathartic (whole bowel irrigation, polyethlene glycol should be added when a potentially toxic intact seed has been ingested) p. 1399*	Few plants have antidote
How long should patients be observed in the ED for, following potential plant exposure and concern for toxic exposure?	ED for 6 hours. p. 1399
What plant derived substance is a potent toxalbumin, which comes from castor bean, that inhibits protein synthesis and causes severe cytotoxic effects on multiple organ systems?	Ricin p. 1399
Patient reports to you w/sxs c/w AGE, which can be severe or hemorrhagic, followed by delirium, seizures, coma or death? THis is ~ 6-8 H after a suspected exposure?	Ricin p. 1399
What nerve impairment occurs with exposure to Coyotillo?	Ascending Nerve Paralysis p. 1400
A child is brought to the ER w/uncertain exposure type. MOP states that the patient was chewing on a bean, but did not swallow it. States tha following this, he started acting 'funny'and developed a seizure after developing AGE sxs. What caused this and what is the prognosis? (can happen even without ingestion, just chewing)	1. Jequirity bean 2. Since this is a child, not a great prognosis. Even adults have been known to die from this crap! p. 1400
What agents are similar to Digoxin?	1. Foxglove 2. Lilly of the Valley 3. Oleander p. 1400
What is the most toxic of all the glycoside containing plants (lilly of the valley, foxglove, oleander) which is the most toxic?	Oleander p. 1400
Ingestion of this unripened fruit leads to hypoglycemia and ecephalopathy, what is it and then how is it treated?	1. Unripened Ackee Fruit 2. 50% Dextrose in water IV immediately- followed by continuous infusion with 10% Dextrose in water IV to maintain euglycemia... - and of course admission for observation. p. 1400
What topical plant therapy, if ingested is a cathartic that can also cause red urine and nephritis?	Aloe p. 1400
Patient was mowing his grass in San Antonio, and ran into a cactus growing in on his property. The site is on the back of his arm, and remains irritated. Is uncertain if he got all the "pricklies" out. Does it matter? If so, how is it treated?	1. Yes, these spines contain proteinacious material that should be removed. 2. Apply rubber cement over the area, let it dry and then "gently" peel this off. p. 1400
What substance is contained in Autumn Crocus, meadow saffron, and glory lily; which causes gastroenteritis and then severe multiorgan system failure. If the patient survives, they will often then experience alopecia?	Colchicine p. 1402	MC supportive tx. However, there is a colchicine Fab treatment that is available- however, it remains experimental and has not been FDA approved.
Patients friend states that he took "some plant crap to get high...then this"...you see a patient who has flushed skin, feels warm-hot, dry mucous membranes, dilated pupils, delirious, tachycardic, with distended abdomen. What do you provide?	- GI Decon for toxin unknown time, for whole bowel irrigation, which may be useful up to 48 hrs after exposure. -IV fluids and external cooling. This was likely a jimson weed exposure. - p. 1402 - what happens if this supportive tx doesn't work	- provide physostigmine: cholinesterase inhibitor, if needed.
Pt's mother comes running into the ER after picking up the child from her fathers. The child, now limp, had difficulty with walking (ataxia), in the car seemed to describe bizarre things around her like she was hallucinating, but was seizing in the parking lot..and now appears to be comatose. MOP states that the child is usually in good health, no significant hx. States that she is unsure what may have happened, since the child was with her dad. MOP/FOP divorced, since FOP was arrested years ago on drug possession charges, Marijuana and heroine. However, she is court ordered to allow visitations, following rehabilitation. What may the child have ingested or been exposed to?	Ingestion of Marijuana - cannabis ingestion by children leads to these sxs. p. 1402
A pts friend dared her to eat peach, apricot, pear and crab apple pits of large quantities, thinking she wouldn't do it. What is the risk for this patient?	Cyanide Toxicity p. 1403	- this often takes hours to develop. Diaphoresis, N/V, abdominal pain, and lethargy. GI decontamination, using activated charcoal and whole bowel irrigation is needed. Sxs should be treated as cyanide toxicity.
What should be done with pepper spray to the eyes?	- corneal abrasions may occur, esp if sprayed in the eye. Irrigation with copious amts of irrigation. - if pepper extract is in mouth- Try demulsifying agent: milk or ice cream. p. 1403
A patient was drunk at a Christmas party with some friends. The drinking and the bets got out of control and the patient is brought in following consumption of 15+ holly berries and poinsettias. What is the concern?	- Serious: as little as three holly berries can cause significatn GI sxs. Ingestion of approximately 20-30 can be fatal. Provide brisk GI decontamination: activated charcoal and IV fluids. - As for the poinsettia, irritation but not toxic p. 1403
A mother brings her child into the ER following catching her eating mistletoe that had fallen on the floor, during their Christmas party. She is not sure how much was consumed, but is sure she had just eaten leaves no berries. Her grandmother told her that these things are not toxic, but she wanted to be sure. Your attending says, it's true and walks out...is that accurate?	No, actually, the entire plant is poisonous. Containing the poison: phroatoxin and toxalbumin. Gastroenteritis is likely to occur, but lethality is rare. However, GI decontamination w/activated charcoal as well as fluid and electrolyte monitoring is imperative. p. 1403
When considering high altitude illness/concerns, what is "the critical altitude to consider"?	Sleeping altitude - since hypoxemia is maximal during sleep. p. 1404
What is "ventilatory acclimatization"? When does it occur?	1. Hyperventilation, causing respiratory alkalosis, which is compensated w/metabolic acidosis (blowing off CO2, urinating off HCO3)- hyperventilation then continues...maximizing ventilation... 2. 4-7 days p. 1404
What is Acetazolamide?	Carbonic Anhydrase Inhibitor, Diuretic. Used for altitude sickness...forces bicarb diuresis. p. 1404
How long before altitude induces erythropoietin levels? How long before a mass increase in RBC's?	- within 2 hours E-poeitin increases - over days to weeks, RBC's increase in mass. p. 1404
What happens to 2,3 DPG and Oxyhemaglobin Dissociation curve at high altitudes?	- 2,3 DPG increases - Dissociation curve shifts to the right p. 1404	Naturally occurring left shift is advantageous at high altitudes
With regard to high altitude travel, what is considered the hallmark of acute mountain sickness?	Antidiuresis... - p. 1404	peripheral venous constriction on ascent to altitude causes an increase in volume, which tiggers the baroreceptors to prevent further release of ADH and Aldosterone, which causes diuresis and decreased blood volume
What is the effect on the pulmonary vasculature in the presence of high altitude changes?	Vascular constriction p. 1404
Finish the following: Although the different hypoxic clinical syndromes overlap, all share a fundamental mechanism, all are seen in the same setting of the rapid ascent in unclimatized persons, and all respond to the same essential therapy...(which is what)	descent and oxygen administration p. 1404
An unacclimatized person can become unconscious at what SaO2 on ascent? What can cause this to be reversed?	- 50-60% - immediate oxygen administration, rapid descent and correction of the underlying cause. p. 1404
What is characterized by: HA, GI disturbances, dizziness or lighheadedness, and sleep distruances in acent?	AMS (Acute mountain sickness)- this occurs in gradual insult MC p. 1405
AMS (acute mountain sickness), though MC from gradual ascent can occur in acute, rapid descent as well. How soon do sxs develop, how late?	1-6 hrs sxs will develop, but can be delayed by 1-2 days p. 1405
You are working an outpost on the side of Mt Everest, when an individual presents to you with a bifrontal HA, , lightheadness and shortness of breath...feeling "hungover", has had N/V, anorexia, chills and wanting to sleep all the time. Additionally, reports feeling irritable. What's happening.	AMS- acute mountain sicknes p. 1405
You suspect that an individual has acute mountain sickness, but then has developed sxs of ataxia as well as an altered level of consciousness, what is going on with this poor guy?	High altitude cerebral edema. p. 1405
T/F: The presenting SaO2 is helpful in determing the diagnosis of AMS.	False - presenting SaO2 is typically normal for a given altitude, and percent SaO2 overall correlates poorly with the diagnosis of AMS p. 1405	Sxs can last on avg 15 hours, but can last many days
Acute mountain sickness, what are the three indicated GOALS of tx?	1. prevent progression 2. abort the illness 3. improve acclimatization p. 1405	- early dx is essential, however, initial clinical presentation does not predict eventual severity. Pts must be observed
Acute moutain sickness, what are the three PRINCIPLES of treatment?	1. do not proceed to a higher sleeping altitude in the presence of sxs 2. descend if sxs do not abate or become worse despite treatment 3. descend and treat immediately in the presence of a change in consciousness, ataxia, or pulmonary edema. p. 1405
You have a patient with severe AMS, however, descent is not possible. What medication is very helpful in speeding acclimatization and aborting illness, especially when used early?	Acetazolamide p. 1406	- it works by mimicking the process of ventilatory acclimatization...
What are the indications for acetazolamide administration?	1. hx of altitude illness 2. abrupt ascent to > 3000m 3. AMS requiring treatment 4. bothersome periodic breathing during sleep - the dosage regimen is: 5 mg/kg/d PO in 2-3 divided doses is sufficient for prevention; 125 mg PO twice daily is effective for prevention. p. 1406*
A patient reports that they are unable to take sulfa drugs, 2/2 to hx of rash. Can they take acetazolamide?	Yes, hx of a rash is not a rxn enough to not provide therapy. However, cannot provide to those who have a hx of anaphylaxis. p. 1406*
What drug causes the recipient to taste the carbon in carbonated beverages after administration?	Acetazolamide p. 1406*
What is the best sleep aid to use in those who have sleep difficulties: waking frequently in elevated altitudes?	Diphenhydramine - then consider Zolpidem, causes less resp depression than other sleep aids, but more expensive than diphenhydramine. p. 1406
What is the best prevention for ascent sxs?	graded ascent with adequate time for acclimatization. p. 1406*
How is high altitude cerebral edema defined?	Neurologic deterioration in someone with AMS or HAPE (high altitude pulmonary edema) p. 1406
What is the treatment for high altitude cerebral edema? And what of all tx possibilities is the highest priority?	1. oxygen supplementation 2. descent 3. steroid therapy - descent is the highest priority p. 1406*
What is the most lethal of high altitude illnesses?	High altitude pulmonary edema p. 1407	Reversible with descent and oxygen administration
Early diagnosis is critical, and decreased exercise performance and dry cough are enough to raise suspicion of what high altitude illness?	High Altitude Pulmonary Edema p. 1408*	- Worse MC at night and by the second day. Audible rales are not present in 30% of the patients with High Altitude Pulmonary Edema...but can be elicited after exercise/activity
Why is the key to High Altitude Pulmonary Edema (HAPE) "early recognition"?	Because in it's early stages it is easily reversible. p. 1408
While CCB's, Nitroglycern as well as phosphdiesterase 5 inhibitors, and steroids are useful medications, what is the ideal tx for HAPE?	- oxygen and descent are the mainstay of treatment for this. p. 1408*
High altitude retinopathy, how long does it take for this to resolve?	10-14 days p. 1409
What is the condition for which an individual has developed excessive polycythemia for a given altitude, causing sxs of a HA, muddled thinking, difficulty with sleeping, impaired peripheral circulation, drowsiness and chest congestion?	chronic mountain sickness. p. 1409
T/F: UVA and UVB light penetrate the atmosphere with a greeater degree at higher altitudes and can cause corneal burns in 1 hr...but sxs may not be apparent for 6-12 hours.	True - while self limiting in 24 hrs, it is disabling. Prevention is the key p. 1409
T/F: there are other neurologic changes that can occur at elevated altitudes: altitude syncope, cerebrovascular spasm (ie. migraine), cerebral venous or artery thrombosis, TIA, and cerebral hemorrhage.	True p. 1409- ** (bolded): "Focal neurologic signs should be thoroughly evaluated and not attributed to high altitude illness".

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