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Ohio ACEP Board Review: Environmental Emergencies I

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Part 1 of a 2 Part Series on Environmental Emergencies

Part 1 of a 2 Part Series on Environmental Emergencies

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  • Coagulation – surface tissue necrosis of initial burn eschar; caused by the insult
    Stasis – deep and peripheral to coagulation; cells are viable but can be further damaged; fibrin deposition, vasoconstriction, thrombosis
    Hyperemia – peripheral to and below stasis; minimal cell injury; vasodilatation due to mediators
  • Zone of coagulation—This occurs at the point of maximum
    damage. In this zone there is irreversible tissue loss due to
    coagulation of the constituent proteins.
    Zone of stasis—The surrounding zone of stasis is
    characterized by decreased tissue perfusion. The tissue in this
    zone is potentially salvageable. The main aim of burns
    resuscitation is to increase tissue perfusion here and prevent
    any damage becoming irreversible. Additional insults—such as
    prolonged hypotension, infection, or edema—can convert this
    zone into an area of complete tissue loss.
    Zone of hyperaemia—In this outermost zone tissue perfusion is
    increased. The tissue here will invariably recover unless there is
    severe sepsis or prolonged hypoperfusion.
  • Burn size formulas use only 2nd and 3rd degree burns.
  • 1st degree sunburn sustained in a tanning bed
  • Coagulation – surface tissue necrosis of initial burn eschar; caused by the insult
    Stasis – deep and peripheral to coagulation; cells are viable but can be further damaged; fibrin deposition, vasoconstriction, thrombosis
    Hyperemia – peripheral to and below stasis; minimal cell injury; vasodilatation due to mediators
  • As ROSC precedes resolution of respiratory arrest, a patient’s ventilation should be supported as soon as possible.
    This highlights the need for a “reverse triage” system for lightning strike victims in which priority is initially given to those individuals without vital signs or spontaneous respirations
    This was the “rash” on the left side of the patient’s chest. It is ferning, or the Lichtenberg figure; which is pathognomonic for lightning strike. Not terribly common. It is not a burn, although the mechanism is unknown.
  • Consider adding Respiration to this list; Respiratory heat loss increases with exertion, cold dry air, and
    altitude.
  • Body is slowing down; With the onset of moderate hypothermia at approximately 32-C, the body’s attempts to combat cooling begin to fail.
    Physiologic changes typically include respiratory depression, vasodilation, depletion of blood volume, cardiac instability, circulatory
    insufficiency, and depressed mental status. Patients may
    lapse from confusion into stupor, and rescuers may note irrational
    or combative behavior and even paradoxical undressing.
  • “Not dead until you’re warm and dead”
  • In a cold prehospital environment, intravenous fluids cool rapidly, and cold fluids may aggravate hypothermia. A considerable volume of fluid
    is often required because of the volume loss with cold diuresis (renal-fluid wasting due to hypothermia-induced vasoconstriction and diminished release of antidiuretic hormone) and vasodilatation during rewarming
  • Afterdrop refers to the continued decline in core temperature even after the patient is removed from a cold environment. In part, this is due simply to ongoing conduction of heat out of the core, but it is promoted further by patient exertion, by cold (room temperature) intravenous (IV) fluids, and by warming the periphery before the core, leading to the dumping of cold, acid blood back into the central circulation before cardiac function and adequate blood volume are established.
  • Hypothermia can be staged clinically on the basis of vital signs with the use of the Swiss staging system of hypothermia (stages HT I to HT IV)10 (Table 2); this system is favored over traditional staging (mild, moderate, severe, and profound hypothermia) whenever the core temperature cannot be readily measured.
  • Mild-to-moderate illness due to water or salt depletion that results from exposure to high environmental heat or strenuous physical
    exercise; signs and symptoms include intense thirst, weakness, discomfort, anxiety, dizziness, fainting, and headache; core temperature may be normal, below normal, or
    slightly elevated (>37°C but <40°C)
  • Heat exhaustion is treated with liberal volume and electrolyte replacement after cessation of all
    immediate activities.
    • Specific treatment includes:
    o Removal from the direct sunlight into a cool, shaded area
    o Restrictive clothing should be loosened
    o Aggressive oral hydration
    o If the patient is hyperthermic (> 38°C), active cooling measures should be initiated.
    Ø One very effective way to cool a hyperthermic patient is to make the patient “sopping wet”
    with tepid (comfortable room temperature) water and fan the patient with anything that
    increases air movement and thus evaporation of the water.
    Ø Ambient temperature water lessens the shivering reaction and helps to keep the skin vessels
    dilated, which increases heat transfer.
    Ø Shivering will increase core body temperature and should be avoided.
    • Oral hydration should adhere to the following guidelines:
    o Cold water or sports beverage
    o Beverage should not exceed 6% carbohydrate content. Increased carbohydrate content inhibits
    gastric emptying and fluid absorption.
    o A general rule is that every pound lost to sweat should be replenished with 500 mL or 2 cups of
    fluid.
    o The treatment goal for mild heat exhaustion should be 1 – 2 liters over 2 – 4 hours.
  • The name refers to the heavy wings of the insects, and is derived from the Ancient Greek ὑμήν (humen): membrane and πτερόν (pteron): wing.
  • Transcript

    • 1. Environmental Emergencies I Nicholas E. Kman, MD FACEP Associate Professor The Ohio State University Department of Emergency Medicine
    • 2. Objectives  Thermal Injuries  Burns  Electrical Injuries  Lightning Injuries  Cold Related Injuries  Hypothermia  Frost Bite  Heat Related Illness  Insect Bites and Stings
    • 3. General Environmental Pearls  Very young and very old are most at risk  Due to lack of or loss of protective adaptations  Underlying disease, medications, poor nutrition  “Multiple system” injuries  Most are largely preventable and respond to common sense treatment  Increased exposure correlates with increased risk
    • 4. Thermal Injury
    • 5. Statistics  More than 1 million burn injuries per year in US  About 45,000 hospitalized (about 4.5% of all patients)  18-35 year old age group  Scald burns: 1-5 year old age group  4% mortality from major burns  Increased risk of death: increased burn size, increased age, presence of inhalational injury, female sex
    • 6. Burn Zones of Injury  Gomez, R.; Cancio, LC. “Management of burn wounds in the emergency department.” Emergency Medicine Clinics Of North America, v. 25 issue 1, 2007, p. 135-46.
    • 7. Burn Zones  Coagulation – surface tissue necrosis of initial burn eschar; caused by insult (irreversible)  Stasis – deep and peripheral to coagulation; cells are viable but can be further damaged; fibrin deposition, vasoconstriction, thrombosis (salvageable)  Hyperemia – peripheral to and below stasis; minimal cell injury; vasodilatation due to mediators (usually recovers)
    • 8. Burn Size  Quantified as body surface area (BSA)  Rule of nines  Palm of patient’s hand is approx. 1% BSA  Lund and Browder burn diagram - more precise - age-adjusted
    • 9. Rule of 9’s
    • 10.  Lund and Browder burn diagram - more precise - age-adjusted
    • 11. Burn Depth  Based on need for surgical intervention  No objective method for measuring depth  Based on clinical features/judgment  Burns are dynamic
    • 12. First Degree  Only epidermal layer  Skin red, painful and tender without blisters  Heals in about 7 days  Symptomatic treatment
    • 13. Second Degree  Superficial partial-thickness  Deep partial-thickness
    • 14. Superficial Partial Thickness  Epidermis and superficial dermis injured  Skin blistering, moist at blister’s base, painful  Heals in 14-21 days  Scarring is minimal
    • 15. Deep Partial Thickness  Extends deep into dermis, damaging hair follicles, sweat and sebaceous glands, but deeper parts survive  Skin may be blistered, pale white to yellow, absent pain sensation  Heals in 3 weeks to 2 months  Scarring common  May require surgical debridement or grafting ATLS
    • 16. Full Thickness-Third Degree  Entire thickness of skin involved – full thickness  All epidermal and dermal structures are destroyed  Skin is charred, pale, painless and leathery  Will not heal spontaneously  Surgical repair and grafting are needed
    • 17. Fourth Degree  Extends through skin into subcutaneous fat, muscle and even bone  Devastating, life-threatening  Amputation or extensive reconstruction needed
    • 18. Inhalational Injury  Main cause of mortality in the burn patient  Closed-space fires  Thermal injury usually limited to upper airway  Toxic inhalants – carbon monoxide, hydrogen cyanide  Damages cells and causes edema of airways  No single method to demonstrate full extent of injury
    • 19. American Burn Association  Classification of burns – major, moderate and minor  Burn unit referral criteria
    • 20. ABA Burn Unit Referral  Partial-thickness burns >10% total body surface area (BSA)  Burns that involve face, hand, feet, genitalia, perineum or major joints  Third-degree burns in any age group  Electrical burns, including lightning injury  Chemical burns  Inhalation injury  Source: American Burn Association
    • 21. ABA Burn Unit Referral  Burns with preexisting medical disorders that complicate management, prolong recovery or affect mortality  Patients with burns and concomitant trauma (such as fractures) in which burn injury poses greatest risk of morbidity or mortality  Burned children in hospitals without qualified personnel or equipment for peds  Burn patients requiring special social, emotional or long-term rehabilitative intervention  Source: American Burn Association
    • 22. Treatment  Airway with c-spine immobilization  For facial burn, singed nasal hair, soot in mouth-  Early intubation  100% O2  COHgb level
    • 23. Fluid Resuscitation  Parkland formula: 4 ml x wt (kg) x % BSA  ½ over 1st 8 hrs. from time of burn  Other ½ over the subsequent 16 hrs.  Second- and third-degree burns only  Children – 3 ml x wt (kg) x % BSA + MNT  Lactated ringers  Check perfusion – Urine OP, HR, BP
    • 24. Burn Zones and Resuscitation  Hettiaratchy, S.; Dziewulski, P. “ABC of burns: pathophysiology and types of burns.” BMJ: British Medical Journal, v. 328 issue 7453, 2004, p. 1427-9.
    • 25. Secondary Assessment  Head to toe assessment  Check for corneal burns of eyes  Calculate BSA  NG tube, foley for more than 20% BSA burns
    • 26. Diagnostic Studies  CBC, BUN, Cr, glucose  Blood gas  UA – myoglobin  CXR – inhalational injury  ECG – electrical injury
    • 27. Special Considerations  Electrical injuries, incineration burns and crush injuries may produce rhabdomyolysis and myoglobinuria – acute renal failure  Thermal injury + multi-system trauma – will have greater fluid needs than calculated  Those with preexisting pulmonary or cardiac disease need much greater attention to fluid management
    • 28. Quiz  A 52 year old male is rescued from a burning building. He has blistering to his chest, carbonaceous sputum, a hoarse voice, and circumferential burns to the right arm. What is the primary treatment priority?  A. Escharotomies of the R arm  B. Silvadene to the chest  C. Cyanide treatment  D. Airway management
    • 29. Quiz  A 52 year old male is rescued from a burning building. He has blistering to his chest, carbonaceous sputum, a hoarse voice, and circumferential burns to the right arm. What is the primary treatment priority?  A. Escharotomies of the R arm  B. Silvadene to the chest  C. Cyanide treatment  D. Airway management
    • 30. Electrical Injuries  1000 - 1300/year in U.S.  25% lightning (30% mortality)  15% overall mortality  High-risk groups  Electricians/builders  Industry  Toddlers
    • 31. Electrical Injuries Pearls  Longer duration=worse injury (except with lightning).  Effects are usually worse with AC than DC at the same voltage (flexor tetany, victim locks up to charge)  High-voltage electrical injuries (>1000V) are at increased risk for spinal injury (immobilize!)
    • 32. Electrical Injuries Pearls  Look for entrance and exit wounds (bull’s eye with charred center)  Treat myoglobinuria  Admit high voltage burns and symptomatic low voltage exposures  If EKG changes or LOC, 24 hours of monitoring is indicated.
    • 33. Lightning Injuries Pearls  “Resuscitate the dead”-Reverse Triage  Massive fluid resuscitation seldom necessary  Think about this in confused patient or unconscious patient with no shoes/clothes  Entrance or exit wounds are rare, but look for Lichtenberg figure
    • 34. Burn General Wound Care  Clean with mild soap/water or dilute antiseptic  Leave blisters intact unless over joint  Debride broken blisters  Anti-microbials  Change dressing twice daily while weeping  Daily dressing change thereafter  Re-evaluate in 24 hours
    • 35. Anti-Microbials  Reduce bacterial colonization  Enhance rate of healing  Silver sulfadiazine 1%: easy, not on face  Triple-antibiotic: face, small areas  Aquacel: occlusive dressing with silver, left in place until separation occurs  Mepilex Ag: newer dressing
    • 36. Other Care  Tetanus prophylaxis  Pain control  For transfer – dry sterile dressings for large burns; moist, saline-soaked dressings for small areas only  Circumferential burns – may need escharotomy http://lifeinthefastlane.com/trauma-tribulation-005/
    • 37. Quiz  A 30 year-old male is struck by lightning and is pulseless and apneic. Which is correct?  a. CPR is not necessary as his heart will start beating on its own  b. CPR is not helpful as his heart likely sustained irreversible damage  c. CPR should be initiated and continued until he begins breathing on his own, then you may stop  d. CPR should not be initiated as the patient may have a residual charge from the lightning
    • 38. Quiz  A 30 year-old male is struck by lightning and is pulseless and apneic. Which is correct?  a. CPR is not necessary as his heart will start beating on its own  b. CPR is not helpful as his heart likely sustained irreversible damage  c. CPR should be initiated and continued until he begins breathing on his own, then you may stop  d. CPR should not be initiated as the patient may have a residual charge from the lightning
    • 39. Hypothermia and Frostbite
    • 40. 41 Brown DJ, Brugger H, Boyd J, Paal P. Accidental hypothermia. N Engl J Med. 2012;367(20):1930-8.
    • 41. Hypothermia  Yearly, about 1500 patients in US have hypothermia noted on their death certificate.  Exact incidence is unknown.  Most cases occur in urban setting and related to exposure attributed to alcoholism, illicit drug use, mental illness, advanced age or homelessness  Other affected groups include people in an outdoor setting for work or pleasure
    • 42. Definition  Accidental or intentional drop of body core temperature to 35° C or below  95°F corresponds to 35°C, and 82°F to 28°C, thresholds of mild and severe hypothermia.  Mild – 32-35° C  Moderate – 28-32° C  Severe - <28° C
    • 43. 4 Mechanisms of Heat Regulation  Evaporation: most efficient  30% body cooling at average temperatures due to evaporation.  Radiation: transfer of heat between body and environment via electromagnetic waves.  Accounts for >50% of cooling, as long as ambient air temperature is lower than body temperature.  Conduction: Direct transfer of heat between two objects in direct contact.  Important when lying on cold ground or immersed in water.  Convection: Heat transfer between body and a moving gas or liquid – typically air and water.  Think of a fan in a hot bedroom.
    • 44. Causes of Hypothermia  Decreased heat production – endocrine derangements, malnutrition, neuromuscular inefficiencies  Increased heat loss – immersion, vasodilatation from pharmacologic or toxic causes, burns  Impaired thermoregulation – CNS trauma/tumors, strokes, toxic and metabolic derangements, ICH  Other – sepsis, uremia, multiple trauma
    • 45. Mild (32-35° C)  Cold temperature defense mechanisms are still working  Shivering, pale and cold  Lethargy, confusion, altered judgment  Loss of fine motor coordination  Ataxia  Apathy
    • 46. Moderate (28-32°C)  BP, HR, and RR decreased  Delirium  Slowed reflexes  Stop Shivering (require active rewarming)  Stupor  At risk for dysrhythmias  Further CNS depression
    • 47. Severe (<28°C)  Unresponsive or comatose (look dead)  Dysrhythmias common, including ventricular fibrillation (rewarming needed to convert)  Rigidity  Apnea  Absent pulse  Areflexia and fixed pupils
    • 48. CNS  Progressive deterioration from confusion to coma  Areflexia below 28° C patellar reflex is last to disappear  EEG – flat at about 19° C  If not a primary exposure, need to investigate for CNS pathology
    • 49. Cardiovascular  Bradycardia  Dysrhythmias – initially atrial fibrillation  Decreased cardiac output  Hypotension  Risk of ventricular fibrillation greatest <22 C  J wave or Osborne wave
    • 50. J wave or Osborne wave
    • 51. J wave or Osborne wave
    • 52. Respiratory  Initial stimulation of respiratory drive  Progressive decline in minute ventilation  Bradypnea  Bronchorrhea  Cough is impaired and aspiration is common  Pulmonary edema
    • 53. Other Systems  “Cold diuresis” so these patients are often very hypovolemic  GI motility is decreased  Insulin is inactivated
    • 54. Diagnostics  CBC, coagulation studies  UA, BUN, Cr  Electrolytes, glucose  CXR  ECG  ABG – DO NOT CORRECT
    • 55. Treatment  Handle all victims carefully  Prevent further heat loss  Anticipate an irritable myocardium and hypovolemia  Treat hypothermia before treating frostbite
    • 56. Treatment  Immobilize c-spine if any question of trauma  Airway – intubate if necessary; be ready for dysrhythmias  Breathing – provide warm oxygen  Circulation – IV NS; avoid LR initially  Disability – record quick neurologic exam  Expose – remove wet clothes, look for injuries
    • 57. Treatment  Measure temperature with low-reading esophageal, rectal or bladder thermometer  Consider thiamine, D50, narcan  Use fluids before vasopressors  Look for hidden trauma  Look for potential cause  Watch for “afterdrop”
    • 58. Rewarming  Active Rewarming necessary for Moderate to Severe  Passive external  Active external  Active internal (core)
    • 59. Passive Rewarming  Passive external:  Remove wet clothing  Block the wind  Keep dry  Cover with dry insulating materials, i.e., clothes, blankets, sleeping bags, “space” blanket
    • 60. Active External Rewarming  Active Rewarming necessary for Moderate to Severe  Active external  Apply hot water bottles, bags of saline to core areas, i.e., neck, axillae, groin – avoid thermal burns  Heat lamps or forced-air heating systems  Immersion in 104 F water (impractical for most of our ED patients)
    • 61. Active Internal (Core) Rewarming  Heated humidified oxygen via mask or ETT  Heated IV fluids  Gastric, bladder, rectal lavage – very little heat transfer, potential complications  Peritoneal lavage  Thoracic lavage  Cardiopulmonary bypass
    • 62. Swiss Staging System 63
    • 63. Quiz  What is the best treatment for a hypothermic patient (core temperature 30 C) who is manifesting ectopy on the monitor?  A. Lidocaine  B. Defibrillation  C. Rapid Rewarming  D. Overdrive Pacing
    • 64. Quiz  What is the best treatment for a hypothermic patient (core temperature 30 C) who is manifesting ectopy on the monitor?  A. Lidocaine  B. Defibrillation  C. Rapid Rewarming  D. Overdrive Pacing
    • 65. Frostbite-Freezing of the skin  Pre-Freeze – secondary to chilling; vasospasticity  Freeze-Thaw – caused by actual ice crystal formation  Vascular stasis – changes in blood vessels, including spasticity and dilation; plasma leakage, stasis coagulation, thrombosis  Late Ischemic – result of thrombosis; tissue necrosis, gangrene Photo: N. Kman, MD
    • 66. Degrees of Injury  Difficult to predict extent of injury on initial evaluation  Classified like burns  Fingers, toes, nose, ears, and genitalia are first to suffer  Symptoms: coldness, numbness, stinging, burning, pain, throbbing ATLS
    • 67. First Degree (Superficial)  Erythema  Numbness  White or yellowish plaque  Edema
    • 68. Second Degree (Superficial)  Erythema  Edema  Superficial blisters  Blisters with clear or milky fluid
    • 69. Third Degree (Deep)  Complete freezing of skin and tissue  Deeper blisters with hemorrhagic fluid  Injury is deep into the dermis
    • 70. Fourth Degree (Deep)  Injury is completely through the dermis and involves the subcuticular tissues  Leads to mummification with muscle and bone involvement
    • 71. Treatment  Address life-threatening conditions first, esp. hypothermia  Rapid rewarming is treatment of choice  Do NOT rewarm if there is any chance of re-freezing  Do NOT rewarm by massaging  Treat like a burn
    • 72. Treatment  Immersion in circulating warm water (40-42°C)  Narcotics are often needed  Rewarm until the skin is pliable and erythematous at the most distal part  Blisters – care is controversial although most agree to debride clear blisters  Tetanus prophylaxis
    • 73. Treatment  Pad between fingers, toes, and all splints  Elevate  Ibuprofen  Aloe vera  Observation for necrosis and demarcation
    • 74. Quiz  Which degree of frostbite is associated with full- thickness skin involvement with muscle and tendon involvement & hemorrhagic bullae?  a. First degree  b. Fourth degree  c. Second degree  d. Third degree
    • 75. Quiz  Which degree of frostbite is associated with full- thickness skin involvement with muscle and tendon involvement & hemorrhagic bullae?  a. First degree  b. Fourth degree  c. Second degree  d. Third degree
    • 76. Heat-Related Illness Photo: N. Kman, MD
    • 77. Statistics  About 500 die each year in the U.S.  Hard to know exact number because it’s often under- reported  800 dead in Chicago 1995  August 2003: at least 35,000 died in Europe  2006 North America: at least 225 deaths  2006 Europe: 1000 heat-related deaths in the Netherlands
    • 78. Heat Illness  Elderly are at risk for classic heatstroke  Children: 3 risk groups 1. neonates 2. toddlers 3. adolescents
    • 79. Mechanisms  Increased heat production  Decreased heat dissipation – radiation and evaporation  Impaired thermoregulation – illness, drugs, behavior
    • 80. Spectrum of Illness Heat Edema Heat Syncope Heat Cramps Heat Exhaustion Heat Stroke
    • 81. Heat Cramps  Painful spasmodic cramps that usually occur in heavily exercised muscles (Large Groups, Calves)  Onset may be during exercise or after  Likely the result of water and sodium loss  Oral rehydration with water and electrolytes  Rest in cool environment  Stretch and massage
    • 82. Heat Edema  Peripheral edema developing during the first few days in a hot environment  Usually self-limited – does not require medical therapy
    • 83. Heat Syncope  Orthostatic hypotension resulting from volume depletion, peripheral vasodilatation, & decreased vasomotor tone.  Trendelenburg  Cool victim and administer oral fluids – carbohydrate-containing fluids absorbed up to 30% faster (dilute Gatorade)
    • 84. Heat Exhaustion  Flulike symptoms – intense thirst, malaise, headache, weakness, nausea, anorexia, vomiting  Tachycardia, orthostatic hypotension  Sweating is generally present  Core Temperature is < 104 F  Mental status and neurologic exam are normal
    • 85. Heat Exhaustion  Cool shaded environment  Oral rehydration if capable but may need IVF due to large amounts of volume lost as sweat  Active cooling measures – ice packs to neck, axillae, groin  Spray with tepid water and fan – one of the most effective ways to cool
    • 86. Heat Stroke  Medical Emergency!  Temperature generally > 104° F  MENTAL STATUS CHANGES  Delirium  Seizures  Coma  Skin is usually hot and dry  Classic versus Exertional
    • 87. Heat Stroke  Classic  Environment plays major role  Linked to heat waves  Dry skin  Elderly  Respiratory alkalosis  Exertional  Intrinsic heat production plays major role  All types of weather  Profuse sweating  Athletes  Respiratory alkalosis and lactic acidosis
    • 88. Heat Stroke  Tachycardia  Orthostatic changes, hypotension  Hyperventilation  Bleeding due to coagulation disorders, including DIC  Classic – respiratory alkalosis  Exertional – respiratory alkalosis and lactic acidosis
    • 89. Multi-Organ Dysfunction  Encephalopathy  Rhabdomyolysis  Acute renal failure  Acute respiratory distress syndrome  Myocardial/hepatocellular/pancreatic injury  Intestinal ischemia/infarction  Hemorrhagic complications – DIC
    • 90. Treatment  Immediate cooling  Support of organ-system function
    • 91. Cooling  Ice packs on neck, axillae, chest wall, and groin  Spray with tepid water and fan rapidly to cool by evaporation; massage the skin  Immersion in cool water, if vital signs are otherwise stable  Stop active cooling at core temperature of 102 F  Internal cooling rarely needed/used
    • 92. Treatment  ABCs  IVF – treat volume depletion  Avoid shivering  Benzodiazepines for seizures/shivering  Dantrolene is ineffective  Monitor for complications and treat
    • 93. Good Prognosis  Recovery of central nervous system function during cooling  Expected in the majority of patients who receive prompt and aggressive treatment
    • 94. Poor Prognosis  Coagulopathy with liver hepatocyte damage  Lactic acidosis in classic form  Rectal temperature > 108 F  Prolonged coma of more than 4 hours  Acute renal failure  Hyperkalemia  AST > 1000 U/L
    • 95. Quiz  A patient presents from OSU Football practice with a core temperature of 105 and altered mental status (says he wants to play for Michigan). What is the best cooling technique?  A. Ice Bath to core temperature of 96 F  B. Ice packs to the forehead  C. ECMO  D. Cooling Fans with mist to core temperature of 102
    • 96. Quiz  A patient presents from OSU Football practice with a core temperature of 105 and altered mental status (says he wants to play for Michigan). What is the best cooling technique?  A. Ice Bath to core temperature of 96 F  B. Ice packs to the forehead  C. ECMO  D. Cooling Fans with mist to core temperature of 102
    • 97. Insect Bites and Stings
    • 98. Insect Bites and Stings Casale, Thomas B (04/10/2014). "Clinical practice. Hymenoptera-sting hypersensitivity". The New England journal of medicine (0028-4793), 370 (15), p. 1432.
    • 99. Hymenoptera Stings  Stinging insects kill more people annually than do snakes  About 40-130 deaths per year  Three families  Hornets, wasps and yellow jackets  Bees  Ants and fire ants
    • 100. Hymenoptera and Distribution Freeman TM. Hypersensitivity to Hymenoptera Stings. N Engl J Med 2004;351:1978-84.
    • 101. Reactions  Local  Mild generalized  Severe generalized
    • 102. Local  Majority of cases  Local redness, pain, swelling  May extend more than 6 inches beyond the sting  May persist longer than 24 hours  Remove stinger  Ice, elevate  Antihistamines, steroids, tetanus prophylaxis
    • 103. Mild Generalized  Symptoms away from site– itching, hives, nausea, wheezing  Antihistamines, steroids  Inhaled beta-agonists for wheezing  Tetanus prophylaxis  Local care  Observation for 6-8 hrs  Consider Epi-pen if wheezing
    • 104. Severe Generalized  Classically IgE-antibody mediated  Anaphylaxis, laryngoedema, circulatory collapse, LOC  Most deaths generally occur within 1st hour
    • 105. Severe Generalized  ABCs – intubate early  IVF – support blood pressure  Epinephrine is drug of choice (0.01 mg/Kg of 1:1000 solution) – initially IM but may need IV drip  Steroids  Inhaled beta-agonists for bronchospasm  H1/H2 blockers (Diphenhydramine and Cimetidine)
    • 106. Severe Generalized  Admit all  Home with Epi-Pen  Refer for desensitization therapy
    • 107. Quiz  About how many bee stings does it take to die from venom overdose?
    • 108. Answer  Approx 300-500 stings
    • 109. Ant Stings  Ants sting 9.3 million people each year. Other Hymenoptera account for more than 1 million stings annually.  Fire-ant venom is composed primarily of a transpiperidine alkaloid that causes tissue necrosis.
    • 110. Ant Stings  Most fire-ant stings produce blister within 24 hours, which fills with necrotic material, giving appearance of pustule.  Despite appearance, blisters are not infected and should be left intact. Casale, Thomas B (04/10/2014). "Clinical practice. Hymenoptera-sting hypersensitivity". NEJM, 370(15), p.1432
    • 111. Key Points: Insect Stings  ABC's  Remove Stinger  Epinephrine for generalized reactions  There are NO contraindications to epi  Steroids, Benadryl, Pepcid  Admit all severe reactions, d/c with Epi Pen
    • 112. Questions?