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19 Cards in this Set
- Front
- Back
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What are some possible sources of exposure to carbon monoxide?
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Automotive exhaust
Exhaust from other motors, e.g. motorboat, generators, Zamboni machines, etc. Natural gas furnaces/heaters Varnishes and paint thinner (in the form of methylene chloride). Any fire, especially structure fires and wood- or coal-burning stoves |
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What is the treatment of carbon monoxide poisoning?
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1) Initiate high flow O2 at the highest FiO2 you can get.
2) Stabilize the patient, with attention to intubation if comatose, ruling out intracranial pathology, performing a trauma work-up, and managing complications of CO poisoning, if present. 3) Consider hyper-baric oxygen therapy for patients with the following criteria: - Syncope - Altered mental status - Coma - Seizure - Focal neurological deficit - Acute MI (believed to be due to the CO poisoning) - Blood level >25% (lower for elderly or comorbid conditions - even 10% can be dangerous for them). - Pregnancy with blood level >15% |
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Name at least 2 disadvantages to HBO therapy for carbon monoxide poisoning.
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1) Evidence of efficacy is conflicting, therefore unclear who will benefit (if anyone) and under what circumstances.
2) Patients who are being "dived" cannot be accessed in case of emergency, it can take an hour or more to "ascend" before the chamber can be opened. Therefore, very risky with an unstable patient. |
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While scuba diving, what are the complications of DESCENT? What is the one complication that may require urgent surgical consultation? What are the symptoms?
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The complications of descent are all "squeeze" related and are generally given supportive treatment only, such as decongestants for "ear squeeze" or "sinus squeeze".
The one more serious complication is inner ear barotrauma. This usually occurs during a forceful Valsalva maneuver against an occlude eustachian tube. It results in the rupture of either the round window or the oval window. The symptoms are "roaring" tinnitus, sensorineural hearing loss, and vertigo; it can sometimes require surgical correction. |
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While scuba diving, what is the one clinically significant complication of ASCENT?
Give two reasons why it is potentially concerning. |
Pulmonary barotrauma - i.e. damage to the lung caused by hyperinflation, usually by ascending while holding one's breath.
2 reasons to worry about it: 1) It can cause complications such as pneumothorax or pneumomediastinum. 2) Air can enter the pulmonary venous circulation - which will result in the air traveling to the left heart, which will lead to... arterial gas embolism! (AGE) |
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What are the 3 manifestions of Decompression Sickness (DCS)? What are the symptoms? What is the treatment?
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1) DCS Type 1: "Pain only" DCS. Affects the extremities and skin. Most common complaint is Joint pain, usually a single joint, most commonly knees and shoulders.
Typically described as a deep, aching pain, not better or worse with movement. Skin changes can also occur, usually itching and color changes, compatible with lymphatic obstruction. 2) DCS Type 2: "Serious" DCS. Generally has one of two manifestations: - may present as multiple pulmonary emboli, with cough, hemoptysis, dyspnea, and chest pain - more commonly, presents as an ascending paralysis, affecting various levels and parts of the spinal cord (i.e. combination of motor, sensory, etc) due to the presence of many small emboli. 3) Arterial Gas Embolism: Not really a type of DCS. It can be caused by nitrogen bubbles as in DCS, or by air entering the pulmonary veins following barotrauma. Most devastating when the emboli affect the coronary or cerebral arteries causing MI or stroke symptoms. TREATMENT for all is the same: 1) Place the patient supine (not Trendelenburg, just flat) 2) Give 100% O2 3) Aggressive fluid resuscitation to increase tissue perfusion 4) Rapid recompression in a hyperbaric oxygen chamber. |
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Describe the treatment of High Altitude Illness.
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1) For mild symptoms, terminate the ascent until symptoms resolve. For anything worse, descend!
2) If descent is impossible and symptoms are severe, hyperbaric therapy can be used. 3) Treat headache and nausea with OTC analgesics and Zofran, and ensure good hydration. 4) Provide supplemental O2. 5) Acetazolamide 250mg po bid 6) IF ANY SIGN OF HACE: Add dexamethasone 4-8 mg PO/IV/IM q6h. |
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Define the degrees of hypothermia and list some important clinical features of hypothermic patients.
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1) Mild hypothermia - 32-35 degrees C
- heart rate, blood pressure, and and cardiac output all rise, and the body generally tries to generate heat. 2) Moderate hypothermia - 28-32 degrees C - loss of shivering - drop in blood pressure and cardiac output - slowing of heart rate - resuscitation medications ineffective below 30 degrees 3) Severe hypothermia - below 28 degrees C Generally, as the patient gets colder, you see: - prolongation of PR, QRS, QT - any number of dysrythmias - Osborn (aka "J") wave - cold diuresis - coagulopathy |
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Describe the management of a hypothermic patient.
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1) Handle patient gently, rough handling may precipitate Vfib.
2) Remove all wet clothing and replace with warm blankets. 3) If there is a non-cardiac-arrest rhythm on the monitor, feel for a pulse for 30-45 seconds. Only start CPR if no pulse is detected. 4) If CPR is started, you get one dose of epi and one shock - if the patient doesn't come back to life you have to continue CPR until they are warm - like 30-32 degrees. 5) Now for the rewarming - if the hypothermia is mild (greater than 32 degrees) passing rewarming may be effective. 6) The decision to actively rewarm depends on whether the patient is cardiovascularly stable (heart rhythm and blood pressure), and what their temperature is. The sicker the patient, the more rapid the rewarming: - start with a heating blanket or Bair hugger set to 40 degrees. - Infuse warm IV fluids (40 degrees). - Intubate and ventilate with warmed, humidified air (40 degrees). - If available, and the patient is truly critical, consider extracorporeal re-warming in the OR (i.e. cardiopulmonary bypass). - If not available then next step is body cavity lavage - continuous bladder irrigation is probably the easiest. - Can insert 2 chest tubes and lavage the left chest. - Can do gastric and peritoneal lavage as well. |
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Define the spectrum of heat illness.
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HEAT CRAMPS - painful muscle cramps - caused by excessive sweating and drinking water without electrolytes, resulting in a relative drop in serum Na and Cl.
HEAT SYNCOPE - peripheral vasodilation and relative loss of fluid results in a postural drop in blood pressure resulting in fainting. HEAT EXHAUSTION - headache, nausea, vomiting, malaise, dizziness, muscle cramps - caused by volume depletion with or without depletion of sodium as well. Can be serious, requires IV hydration, electrolyte replacement, and sometimes active cooling if the patient is hyperthermic. HEAT STROKE - A life-threatening emergency where the patient's ability to regulate their temperature has been lost. It can rapidly progress to multi-system organ failure. Comes in two categories - exertional and non-exertional (aka classic). The hallmarks of heat stroke are HYPERTHERMIA > 40 DEGREES C + ALTERED MENTAL STATUS. |
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Describe the treatment of heat stroke.
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1) The overall goal is to cool the patient to 39 degrees C (stop there because otherwise you will overshoot)
2) Excessive fluid administration is unnecessary. Give small boluses and start IV fluids at twice maintenance (about 250 cc/hr). As the patient cools, their vasodilation will resolve and hemodynamics will improve. 3) For inotropes, dopamine or dobutamine are preferred to vasocontrictors like norepinephrine. 4) How to cool: - Remove all the patient's clothing and expose them. - Ice packs in the neck, axillae and groin - Spray them with water and set up fans for evaporative cooling. - Cardiopulmonary bypass, (and to a lesser extent, cold water immersion) is a very inconvenient but effective method that may have to be used. 5) Remember they will be in multi-organ failure so close monitoring of glucose, pH, electrolytes, liver function, etc. is essential. 6) Don't forget to rule out other disease that can mimic heat stroke such as malaria, sepsis, etc. |
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What is the prognosis of a patient who presents to hospital after drowning?
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There are 3 categories of drowning victims:
1) Patients who are asymptomatic or mildly symptomatic on arrival (GCS 13-15, no C-spine injury, normal vitals, no obvious pulmonary complications on exam or on chest Xray). - If they are ok after 4-6 hours of observation, they will be fine. 2) Patients who present with coma or cardiovascular instability (including patients requiring CPR on scene or in the ED) generally do very poorly... UNLESS.... 3) The patient presents with coma or instability after drowning in ICY water and is hypothermic (the hypothermia may provide a slightly better prognosis). |
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What is the treatment of a drowning victim?
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1) Mostly supportive care. If GCS 13-15, no C-spine injury, vitals good and CXR normal on arrival, they can go home with instructions to return ASAP if they develop fever or new respiratory symptoms (infection from the water flora).
2) If GCS less than 13, or low O2 sats, then maintain C-spine precautions, provide antibiotics, positive pressure ventilation, and manage electrolyte disturbances which can arise from aspiration of the water. 3) A patient who presents in cardiac arrest and who is NOT hypothermic has an extremely poor prognosis. |
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What are the degrees/depths of thermal burns?
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1) Superficial, aka first degree - sunburn
2) Superficial partial thickness (aka 2nd degree) - blisters, involves dermis 3) Deep partial thickness (aka 2nd degree) - blisters, involves dermis including hair follicles and sweat glands 4) Full thickness (aka 3rd degree) - charred, leathery, pale. 5) Fourth degree - down to underlying structures (fat, muscle, etc) |
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What is the Parkland Formula?
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Adults: 4 cc of Ringer's Lactate x weight (kg) x BSA (%). Give half that volume over 8 hours, and then the other half over 16. (DO NOT ADD MAINTENANCE).
Children: Calculate maintenance with D51/2NS+20KCl, then add the Parkland formula with 3 instead of 4. TITRATE TO URINE OUTPUT, DO NOT OVER-RESUSCITATE. |
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What are 5 things you should never forget to include when resuscitating a burn patient?
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1) Remember to treat as a TRAUMA patient!
2) Intubate early if any sign of inhalational injury. 3) Measure carboxyhemoglobin. 4) Place Foley and NG. 5) Tetanus |
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What are some indications for referring a patient to a burn centre?
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"Major Burns" that warrent referral to a burn centre:
1) Burns affecting face, joints, perineum 2) Electrical burns 3) Chemical burns 4) Inhalational injury 5) Burn in patients under 10 or over 50 6) Partial thickness burns >25% BSA (or less if under 10/over 50) 7) Full thickness burns >10% 8) Other factors (social, pre-existing medical conditions, or significant associated injuries) that may complicate the care or recovery of the patient. |
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What is the treatment of an alkali burn to the eye?
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1) Immediate and copious irrigation with NS, 1-2 L to start. Check the eye pH and continue irrigation until it comes back at less than 7.4 (could take hours and hours).
2) You should evert the eyelids and sweep them with a cotton swab to help get any stuff out. 3) Immediate ophthalmologist consultation. |
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What are some chemical exposures that require special treatment?
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1) Hydrofluoric acid - covered in another section.
2) Phenol - irrigate with isopropyl alcohol, not water, as dilution makes phenol BETTER able to penetrate the skin. 3) Lime - brush away as much as possible and use a very high flow of water, to dissipate the high amount of heat generated by the exothermic chemical reaction. 4) Burning elemental metals - do not add water or it will cause a reaction - cover in mineral oil or spray with a Class D fire extinguisher. |
