Ohio ACEP Board Review: Environmental Emergencies II

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  • 1. Environmental Emergencies II Nicholas E. Kman, MD FACEP Associate Professor The Ohio State University Department of Emergency Medicine
  • 2. Objectives  Learner will review the following topics:  Snake Envenomations  Spider Bites  Marine Envenomations  Drowning  Dysbarism Dive Medicine High Altitude Illness
  • 3. Snake Envenomations
  • 4. Snake Envenomations
  • 5. Snake Bites  9,000 snakebites annually in U.S. with 2,000 treated as envenomations  Est. 2.5 million venomous snakebites occur internationally, with 125,000 deaths annually.  About 12 deaths/year in U.S.  60% rattlesnakes  Important to know distribution of venomous snakes in your area Lavonas et al. BMC Emergency Medicine 2011, 11:
  • 6. Snake Bites Statistics  Crotalinae – 99% of venomous snakebites in U.S.  65% - rattlesnakes  25% - copperheads  10% - cottonmouths
  • 7. Snake Bites Species of Snakes  Viperidae - rattlesnakes, cottonmouth, copperhead (pit-vipers)  Elapidae - coral snake only member in U.S.; others include cobra and sea snakes Rattlesnakes CopperheadCottonmouth Pit Viper
  • 8. Coral Snake (Elapidae)  Only 1/100 bites in U.S. annually  Distinct red band bordered by yellow stripes  Neurotoxic component to their potent venom  Short fixed fangs making it difficult to envenomate humans
  • 9. Coral Snake (Elapidae)  Effects may be delayed up to 12 hrs  Mild envenomation:  localized swelling only  Severe envenomation:  Any systemic symptoms  Nausea, vomiting, headache, mental status, neurologic  Respiratory distress
  • 10. Coral Snake (Elapidae)  Initial appearance may be innocuous  Early evacuation to prepare for antivenom administration  Evacuate ALL patients with elapidae bites, regardless of symptoms
  • 11. N Engl J Med, Vol. 347, No. 5·August 1, 2002
  • 12. Signs and Symptoms  Check for signs of envenomation: 1 or more fang marks, pain, edema, erythema, or ecchymosis. Bullae may appear.  Systemic effects: AMS, tachycardia, tachypnea, resp distress, hypotension, coagulopathy, renal failure, hemolysis.
  • 13. Snake Bites Grades of Envenomation  Grade 0  Fang marks  No envenomation  Grade I  "Mild" envenomation  Fang marks  Pain and edema at site  Local ecchymosis  Blistering  Necrosis  Minimal to no spread of edema proximal to site Torpy, Janet M (04/18/2012). "Snakebite". JAMA : the journal of the American Medical Association (0098-7484), 307 (15), p. 1657.
  • 14. Moderate  56% of bites  Severe pain  Spreading edema beyond site of bite  Systemic signs – nausea, vomiting, paresthesias, muscle fasciculations, mild hypotension Photo by N. Kman
  • 15. Severe • Marked swelling of extremity that occurs rapidly • Subcutaneous ecchymosis • Systemic symptoms – coagulopathy, hypotension, altered mental status
  • 16. Lavonas et al. BMC Emergency Medicine 2011, 11:
  • 17. SNAKE BITES Management  Maintain vital signs (ABC’s)  Reduce venom effects  Prevent complicated sequelae  Minimize tissue damage
  • 18. SNAKE BITES Immediate First Aid  Get away from the snake  Stay calm  Immobilize the bitten extremity at a position of heart  Apply a constricting band (Coral Snake)  TRANSPORT TO MEDICAL FACILITY http://www.howitworksdaily.com/environment/how-to-survive-a-snakebite/
  • 19. SNAKE BITES  Treatments to Avoid in (Pit Viper) Snakebite  Cutting and/or suctioning of wound  Ice  NSAIDs  Prophylactic antibiotics or fasciotomy  Routine use of blood products  Shock therapy (electricity)  Steroids (except for allergic phenomena)  Tourniquets Lavonas et al. BMC Emergency Medicine 2011, 11:
  • 20. SNAKE BITES ED Management  Notify Regional Poison Center  ABC’s  At least 1 IV line, draw labs while starting  If no signs of envenomation, observe 8 hours for further progression  Measure circumference of limb, mark leading edge every 15-30 minutes  If signs of envenomation, antivenin admin.
  • 21. Snake Bite Antivenin  Polyvalent Crotalinae antivenin  Available in U.S. since 1947  Mainstay of medical management  Horse serum derived  Dosing varies according to severity  Production discontinued in 2002
  • 22. SNAKE BITES Ovine (Sheep Derived) Fab Antivenin (CroFab)  Mix 4-6 vials in 250ml of NS  Additional 4-6 vials until control achieved  Scheduled 2-vial doses at 6, 12, and 18 hr  Initial dose given slowly for first 10 min  Rest of dose over 1 hr
  • 23. SNAKE BITES Other Management  Cleanse wound thoroughly  Tetanus prophylaxis  General supportive care  Opioid Analgesics
  • 24. SNAKE BITES Complications  Compartment syndrome – surgery is rarely indicated; if worried, do pressure monitoring  Serum sickness (type III hypersensitivity) – up to 3 weeks after antivenin; fever, chills, arthralgias, diffuse rash  Rx-steroids and antihistamines
  • 25. Quiz  A 23 year old male was playing with a copperhead when he was surprisingly bit. He had premedicated with about “eleventeen” beers. He is complaining of severe pain, spreading edema, and has mild hypotension. What is the best treatment?  A. Lecture on the dangers of mixing snakes and alcohol  B. 4 Vials of CroFab Antivenin  C. 2 Vials of Horse Serum Derived Antivenin  D. Applying oral suction to the bite site
  • 26. Quiz  A 23 year old male was playing with a copperhead when he was surprisingly bit. He had premedicated with about “eleventeen” beers. He is complaining of severe pain, spreading edema, and has mild hypotension. What is the best treatment?  A. Lecture on the dangers of mixing snakes and alcohol  B. 4 Vials of CroFab Antivenin  C. 2 Vials of Horse Serum Derived Antivenin  D. Applying oral suction to the bite site
  • 27. Spider Envenomations
  • 28. Ohio’s Biting Spiders  2 main groups of spiders; the recluse spiders and the widow spiders.  The black widow, Latrodectus mactans, and the northern widow, Latrodectus variolus.
  • 29. Widow Spiders • Black Widow – Latrodectus mactans • Widespread, esp. SE/SW • Garages, barns, outhouses, foliage • Alpha-latrotoxin: causes increased release of multiple neurotransmitters
  • 30. Black Widow • Initial bite may be no more than a prick • Within 30 min – systemic symptoms • Muscle cramping – local to large groups such as abdomen, back, chest, thighs • Nausea, vomiting
  • 31. Black Widow  May mimic an acute abdomen  Hypertension, tachycardia  Latrodectus facies – spasm of facial muscles, edematous eyelids  Priapism, weakness, diaphoresis, fasciculations may all occur in severe envenomation
  • 32. Treatment  Ice to bite site  Pain medication  Benzodiazepines for muscle spasm  Calcium gluconate no longer recommended  Tetanus prophylaxis  Antivenin – for severe symptoms not relieved by above measures, esp. hypertension; pregnancy
  • 33. Brown Recluse • Loxosceles reclusa • Coast to coast • Attics, closets, woodpiles, storage sheds • Violin-shaped marking • Cytotoxic • Necrotic arachnidism • Local and systemic effects
  • 34. Cutaneous Loxoscelism  Initially a sharp stinging sensation, some report no awareness of being bitten  Over 2-8 hrs aching and itching develop  Bulls-eye lesion: erythema surrounds vesicle circumscribed by a ring or halo of pallor  Necrosis may develop within 3-4 days, becoming ulcerated
  • 35. Brown Recluse Venom  Cytotoxic enyzmes cause destruction of local cell membranes:  Alkaline phosphatase  5-ribonucleotide phosphohydrolase  Esterase  Hyaluronidase  SPHINGOMYELINASE D
  • 36. Brown Recluse
  • 37. Treatment  Immobilization, ice, elevation  Tetanus prophylaxis  Antihistamines  Dapsone?  Skin grafting once area has demarcated  Antivenin - research
  • 38. Systemic Loxoscelism  Rarely correlates with the severity of the skin lesion  Children most at risk  Fever, chills, myalgias, arthralgias, morbilliform rash  DIC, seizures, renal failure, hemolysis  Steroids may decrease amount of hemolysis  Alkalinize urine
  • 39. Quiz  A 19 year old male is reaching into a tackle box when he feels a prick. He thought he poked himself with a fishing lure, but becomes nauseated and presents complaining of severe abdominal pain. On exam, his abdomen is rigid and tender. What is the next best treatment?  A. Exploratory Laporatomy  B. Calcium Gluconate  C. Dapsone  D. Analgesics and Benzos for muscle spasm and pain
  • 40. Quiz  A 19 year old male is reaching into a tackle box when he feels a prick. He thought he poked himself with a fishing lure, but becomes nauseated and presents complaining of severe abdominal pain. On exam, his abdomen is rigid and tender. What is the next best treatment?  A. Exploratory Laporatomy  B. Calcium Gluconate  C. Dapsone  D. Analgesics and Benzos for muscle spasm and pain
  • 41. Marine Envenomations
  • 42. Jellyfish  Coelenterates (Portuguese man-of-war, true jellyfish, hydroid corals, sea anemones, corals)  Coastal areas of U.S.  About 10,000 envenomations each summer off the east coast of Australia  Nematocysts are stinging cells on outer tentacle  Box jellyfish causes most fatal envenomations
  • 43. Jellyfish  Toxin contains complex mixture of proteins and polypeptides  Most common presentation is painful papular- urticarial eruption  Lesions can last for minutes to hours, and rash may progress to urticaria, hemorrhage, ulceration
  • 44. 45
  • 45. 46
  • 46. Jellyfish  Systemic reactions can develop – weakness, headache, vomiting, muscle spasm, fever, pallor, respiratory distress, paresthesias  Seabather’s eruption – intensely pruritic maculopapular eruption on skin that has been covered by swimwear – larvae of thimble jellyfish; develops within 24 hrs of exposure and lasts 3-5 days http://www.sdtn.com/dive_resources/technical_articles/sea- bathers-eruption-and-seaweed-dermatitis-whats- difference#.U-5b8fldV8E
  • 47. Treatment  ABCs  Inactivate nematocysts  Remove
  • 48. Jellyfish Treatment  Rinse with saltwater  Remove tentacles with protected hand  Pour acetic acid (vinegar) on it to inactivate the nematocysts  Until pain ceases  Use isopropyl alcohol if vinegar not available  Scrape off nematocysts  May then use ice to decrease pain  Evacuate patients with continued symptoms or suspected box jellyfish envenomation
  • 49. Removal  Wear gloves for protection  Apply shaving cream, baking soda paste  Shave with razor or other sharp edge  Tetanus prophylaxis  Antihistamines  Watch for infection http://www.prweb.com/releases/2011/10/prweb8913589.htm
  • 50. Echinoderms • Sea urchins, starfish, sea cucumbers • Venoms usually contained in spines • Local effects most common • Systemic effects do occur • Deaths are extremely rare
  • 51. Echinoderms  Remove visible spines  Immersion in hot water for 30-90 minutes  Local or regional anesthesia if hot water alone is not adequate  X-ray or ultrasound to look for retained fragments – surgery may be needed  Tetanus prophylaxis  Watch for infection
  • 52. Quiz  A patient presents to your emergency department after being stung by a jellyfish. At the scene life guard treated with wound with urine, shaving cream, vinegar, sea water, and taco sauce. What is the next best treatment?  A. Local wound care and tetanus prophylaxis  B. More urine  C. Vinegar mixed with shaving cream  D. Cold Tap Water
  • 53. Quiz  A patient presents to your emergency department after being stung by a jellyfish. At the scene life guard treated with wound with urine, shaving cream, vinegar, sea water, and taco sauce. What is the next best treatment?  A. Local wound care and tetanus prophylaxis  B. More urine  C. Vinegar mixed with shaving cream  D. Cold Tap Water
  • 54. Drowning
  • 55. The Eve Method August 1946 copy of Popular Science
  • 56. Szpilman D, Bierens J, Handley A, Orlowski J. Drowning. N Engl J Med. 2012;366(22):2102-10.
  • 57. Terminology  Drowning: Process resulting in respiratory impairment from submersion / immersion in liquid medium. Victim may live or die during or after process. The outcomes are classified as death, morbidity, and no morbidity.  The Drowning Process: A continuum that begins when the victim’s airway lies below the surface of liquid, usually water, preventing the victim from breathing air.  Drowned: refers to a person who dies from drowning
  • 58. Drowning  Second only to MVA as most common cause of accidental death in US  Risk factors:  male sex  age <14 years  alcohol use/risky behavior  Low income/Poor education  rural residency  aquatic exposure  lack of supervision.
  • 59. Drowning Pathophysiology  Most important abnormality of drowning is a profound HYPOXEMIA resulting from asphyxia.  Sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia, pulseless electrical activity, then asystole.
  • 60. Drowning Treatment  Immediate and adequate resuscitation is most important factor influencing survival.  For unconscious: in-water resuscitation may increase favorable outcome by 3 times.  Drowning persons with only respiratory arrest usually respond after rescue breaths. If no response, assume cardiac arrest & start CPR.  Full neurologic recovery is not predicted if victim has been submerged >60 min in icy water or >20 min in cool water.
  • 61. Predictors of Outcome  Early BLS and ACLS improve outcomes (ABC’s)  Duration of submersion and risk of death/severe neurologic impairment after hospital discharge  0–5 min — 10%  6–10 min — 56%  11–25 min — 88%  >25 min — nearly 100% http://ondrowning.blogspot.com/2013/01/lifeguard- fatigue-and-cpr.html
  • 62. Diving Medicine
  • 63. Dysbarism  All the pathologic changes caused by altered environmental pressure  Altitude-related event  Underwater diving accident  Blast injury that produces an overpressure effect
  • 64. Types  Barotrauma – dysbarism from trapped gases  Decompression sickness – dysbarism from evolved gases  Nitrogen narcosis – dysbarism from abnormal gas concentration (“Rapture of the Deep”)
  • 65. Pressure is doubled, volume is halved. PV = K Every 33 ft of descent increases the pressure by 1 atm.
  • 66. Boyle’s Bubbles  Boyle’s law states: pressure of gas is inversely related to its volume.  As pressure increases with descent, the volume of gas bubble decreases, as pressure decreases with ascent, the volume of gas bubble increases.  Air-containing spaces act according to Boyle’s law.  Lungs, middle ear, sinuses and gastrointestinal tract.
  • 67. Middle Ear Squeeze  Barotitis media-Most common diving-related barotrauma  Equalization of pressure via eustachian tube is unsuccessful  Too rapid descent or infection/inflammation  TM is pulled inward & can rupture  Fullness in ears, severe pain, tinnitus
  • 68. Middle Ear Squeeze  PE – erythema or retraction of TM, blood behind TM or rupture, bloody nasal discharge  Reverse ear squeeze occurs on ascent  Treatment – prevention: clear ears during dive  If TM not ruptured – pseudoephedrine and oxymetazoline nasal spray  If TM ruptured – antibiotic for 7-10 days  Suspend diving activities
  • 69. Other Barotrauma  Barotitis externa  Alternobaric vertigo  Barosinusitis  Barodontalgia  Face mask squeeze
  • 70. Pulmonary Over-Pressurization  A too-rapid ascent  Lung emptying is incomplete  Lung volume expands rapidly  Pneumothorax, pneumomediastinum, SQ emphysema, rupture into pulmonary vein causing air embolism  Simple pneumothorax may progress to tension on further ascent
  • 71. Arterial Gas Embolism (AGE)  Results from air bubbles entering pulmonary venous circulation from ruptured alveoli  Usually develops right after diver surfaces  Sudden LOC on surfacing should be considered an air embolus until proven otherwise  Cardiac – ischemia, dysrhythmias, cardiac arrest  Neurologic – LOC, confusion, stroke-like sx
  • 72. AGE Vann, RD.; Butler, FK.; Mitchell, SJ.; Moon, RE. “Decompression illness.” The Lancet, v. 377 issue 9760, 2011, p. 153-64.
  • 73. Arterial Gas Embolism (AGE)  Recompression in hyperbaric chamber  Transport supine, not in Trendelenburg  100% oxygen, intubate if necessary  IVF  Aspirin for antiplatelet activity if not bleeding  Transport in plane pressurized to sea level or helicopter no higher than 1000 ft. above sea level
  • 74. Decompression Sickness (DCS)  Henry’s Law – the amount of a gas that will dissolve in a liquid is proportional to partial pressure of gas over the liquid  Nitrogen equilibrates through the alveoli into the blood, but is 5 times more soluble in fat  The longer and deeper the dive, the more nitrogen gas will be accumulated in the body
  • 75. Decompression Sickness  During a slow ascent, pressure decreases, nitrogen in the tissues is released into blood and alveoli  If ascent is too quick, gas comes out of solution and forms gas bubbles in the blood or tissue  Type I – extravascular gas bubbles  Type II – intravascular nitrogen gas emboli
  • 76. Type I DCS  “The Bends” – periarticular joint pain is most common symptom of DCS  Shoulders and elbows most often affected  Dull, deep ache, mild at first and becomes more intense  Palpable tenderness  Vague area of numbness around the affected joint
  • 77. Type I DCS  Cutaneous – pruritus, cutis marmorata, hyperemia, orange peel  Lymphedema  Fatigue, especially if severe Vann, RD.; Butler, FK.; Mitchell, SJ.; Moon, RE. “Decompression illness.” The Lancet, v. 377 issue 9760, 2011, p. 153-64.
  • 78. Type II DCS  Pulmonary system (The Chokes)  Nervous system (The Staggers)  Decompression shock
  • 79. Cerebral AGE vs. DCS II  Cerebral AGE  May occur after any type of dive  Onset is immediate (<10- 120 min)  Only brain  DCS II  Dive must be long enough to saturate tissues  Onset is latent (often 2- 6 hrs)  Spinal cord and brain
  • 80. Pulmonary DCS  “The Chokes”  May begin immediately after dive but often takes up to 12 hours to develop  Triad – shortness of breath, cough, and substernal chest pain or chest tightness  Cyanosis, tachypnea, and tachycardia
  • 81. Neurologic DCS  Spinal cord is the most common site affected  Lower thoracic and lumbar regions  Low back pain, “heaviness” in legs, paresthesias, possible bladder or anal sphincter dysfunction  Brain – variety of symptoms and difficult to distinguish from AGE  Scotomata, headache, confusion, dysphasia
  • 82. Decompression Shock  Vasomotor decompression sickness  Rapid shift of fluid from intravascular to extravascular spaces (unknown reason)  Rare but often lethal  Weakness, sweating, hypotension, tachycardia, pallor  Despite fluids, hypotension may not respond until recompression
  • 83. DCS Diagnostics  History is most important  Lab used to rule out other conditions and/or obtain baseline measurements  CXR  ECG  CT  MRI  Testing should not delay transfer to HBO
  • 84. DCS Treatment  ABCs  Transport supine, not Trendelenburg  100% oxygen  IVF  Recompression therapy  Divers Alert Network (DAN): 919-684-8111  75-85% have good results when recognition and treatment are prompt
  • 85. Quiz  You are on a plane from Key West to Cleveland when the passenger next to you starts to arch his back and bend his knees. He then starts to rapidly breath and call for the flight attendant. She asks, “is there a doctor on the plane?” What do you do?  A. Lecture the passenger on diving too close to a flight  B. Start high flow O2, keep the patient supine, and get the patient to a hyperbaric chamber upon landing  C. Intubate and hyperventilate
  • 86. Quiz  You are on a plane from Key West to Cleveland when the passenger next to you starts to arch his back and bend his knees. He then starts to rapidly breath and call for the flight attendant. She asks, “is there a doctor on the plane?” What do you do?  A. Lecture the passenger on diving too close to a flight  B. Start high flow O2, keep the patient supine, and get the patient to a hyperbaric chamber upon landing  C. Intubate and hyperventilate
  • 87. High Altitude Medicine
  • 88. High Altitude Illness  Rate of ascent  Altitude reached  Sleeping altitude  Individual physiology
  • 89. High Altitude Illness  Rate of ascent: Graded ascent is safest method to facilitate acclimatization and prevent sickness.  Altitude reached: AMS usually seen at altitudes in > 2000 meters (6560 ft) and caused by hypobaric hypoxia.  Sleeping altitude: Increases >600 meters in sleeping altitude should be avoided.  Individual physiology: Age, gender, and fitness level do NOT play a role in susceptibility to altitude illness.
  • 90. Risk Factors  History of high altitude illness  Residence at altitude below 900 m  Exertion  Preexisting cardiopulmonary conditions  Age < 50 years  Physical fitness is not protective
  • 91. High Altitude Medicine  Acute Mountain Sickness (AMS)  High Altitude Cerebral Edema (HACE)  High Altitude Pulmonary Edema (HAPE)
  • 92. Acute Mountain Sickness  History is key (total elevation gain and rate of gain)  AMS is present if one is at altitude and, if in addition to headache, at least one of the following symptoms is present:  Dizziness or lightheadedness  Fatigue or weakness  Nausea/vomiting/anorexia  Insomnia
  • 93. AMS  Hypoxia  Neurohumeral and hemodynamic responses  Overperfusion of microvascular beds  Elevated hydrostatic capillary pressure  Capillary leakage  Consequent edema
  • 94. AMS  Avoid further ascent until symptoms have resolved  Descend if no improvement in 24 hours or worsening symptoms  Non-narcotic pain relievers for headache  Supplementary oxygen  Acetazolamide, dexamethasone  Gamow bag
  • 95. Acetazolamide  For both treatment and prevention of AMS  Mechanism of action: increase urinary excretion of sodium, potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis, which stimulates ventilation, improving arterial oxygen saturation  Decreases periodic breathing and improves sleeping
  • 96. Acetazolamide  Speeds up acclimatization  250 mg po bid for treatment  125-250 mg po bid starting 24 hr before ascent and the first 2 days at high altitude
  • 97. Dexamethasone  For treatment or prevention of AMS  Does NOT speed up acclimatization  May improve integrity of blood-brain barrier, thereby reducing edema  4 mg po every 6 hrs for treatment  4 mg po every 12 hrs for prevention
  • 98. http://www.jyi.org/issue/on-the-mountains-high-altitude-sickness-in-nepal/
  • 99. High Altitude Cerebral Edema (HACE)  HACE: progression of AMS to life-threatening end-organ damage.  Defined as severe AMS symptoms with additional obvious neurologic dysfunction:  Ataxia  Altered level of consciousness  Severe lassitude  HACE almost never occurs without antecedent AMS symptoms as a harbinger.  The progression of AMS to coma typically occurs over 1 – 3 days.
  • 100. HACE  Progression of AMS  Ataxia is the single most useful sign  Diffuse neurologic dysfunction  Altered mental status, nausea, vomiting, seizures, decreased LOC, coma and finally death  Once coma present – 60% mortality rate  Cause of death – brain herniation
  • 101. http://www.altitudemedicine.org/index.php/altitude-medicine/learn-about-altitude-sickness/what-is-hace
  • 102. HACE Treatment  Descend  Descend !  Descend !!  Oxygen  Dexamethasone 8 mg load followed by 4 mg every 6 hrs  Gamow bag if descent not possible
  • 103. HAPE  Accounts for most deaths from high altitude illness  Non-cardiogenic pulmonary edema  Commonly strikes the second night at a new altitude  Rarely occurs after more than four days
  • 104. HAPE  Early diagnosis is crucial to recovery  Decreased exercise performance  Dry cough initially  Tachycardia and tachypnea at rest  Dyspnea at rest  Rales typically originate in right axilla and become bilateral as illness progresses  Cerebral signs and symptoms are common
  • 105. HAPE Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level. http://radiopaedia.org/images/1564322
  • 106. HAPE  Pulmonary hypertension due to hypoxic pulmonary vasoconstriction  Elevated capillary pressure  Stress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells  Impaired clearance of fluid from alveolar space probably has a role
  • 107. HAPE Treatment  Descent is treatment of choice  Exertion may worsen the illness  Oxygen  Gamow bag if unable to descend  Nifedipine 10 mg po initially, then 20-30 mg extended release every 12 hrs – decreases pulmonary artery pressure  Inhaled beta-agonists
  • 108. http://www.jyi.org/issue/on-the-mountains-high-altitude-sickness-in-nepal/
  • 109. Quiz  You decide to climb to the top of Mt. Everest. While nearing the top, your partner begins to have a seizure and becomes unresponsive. What is the best treatment for him?  A. Prednisone taper  B. Acetazolamide IV  C. High Flow Oxygen  D. Descent
  • 110. Quiz  You decide to climb to the top of Mt. Everest. While nearing the top, your partner begins to have a seizure and becomes unresponsive. What is the best treatment for him?  A. Prednisone taper  B. Acetazolamide IV  C. High Flow Oxygen  D. Descent
  • 111. Questions?