This document discusses heat stroke and heat illness, including causes, management strategies, and cooling techniques. It reviews mortality rates associated with heat stroke. Various cooling methods are presented and compared, including cold water immersion, ice packs, cold IV fluids, mist/water dousing, and fans. The most effective cooling techniques are discussed. Aggressive supportive care and rapid cooling through various means are emphasized as essential to heat stroke treatment.
This document discusses body temperature measurement. It describes the purposes of measuring body temperature as detecting fever, hypothermia, or hyperthermia. It also notes additional purposes like monitoring medicine effectiveness and planning pregnancy. The document outlines normal temperature ranges and describes common sites and types of thermometers for taking measurements, including mercury/glass, electronic/digital, chemical strips, infrared, and temporal artery thermometers. It provides steps for properly taking temperature with an infrared ear thermometer.
This document discusses temperature and how it is measured. It defines temperature as a measure of how hot or cold an object is compared to another object, and that heat flows from warmer objects to cooler ones. Temperature is typically measured using a thermometer. It describes three main temperature scales - Fahrenheit, Celsius, and Kelvin - and notes their reference points for water's freezing and boiling points. The document also provides examples of normal body temperature and room temperature in Celsius. It notes that temperatures above 40°C can be life-threatening, and above 50°C will cause immediate death. The highest recorded surviving human body temperature was 115.7°F (46.5°C), while the lowest recorded survival was 56.6
CSCR Agriculture Track w/ Larry Klotz: Weather or Not - Effects of Changing W...Sustainable Tompkins
Climate Smart & Climate Ready Conference Agriculture Track on April 19, 2013 at NYS Grange in Cortland, NY. Prof. Larry Klotz, SUNY Cortland. Weather or Not: Effects of Changing Weather on Local Agriculture. What is climate change? What are regional implications?
Body temperature is measured in degrees Celsius or Fahrenheit and normally ranges from 36-37.4°C orally. There are core and surface temperatures, with core being more constant near 37°C. Factors like basal metabolic rate, activity, and hormones influence heat production, while radiation, conduction, convection, and vaporization cause heat loss. Fever is a raised temperature over 37.5°C often caused by pyrogens like bacteria. Hypothermia is a lowered temperature below 35°C caused by exposure to cold. Nursing care for temperature issues focuses on monitoring, hydration, comfort measures, and antipyretic administration.
The document discusses thermoregulation and temperature monitoring. It summarizes that the hypothalamus regulates body temperature through heat production and loss mechanisms like radiation, conduction, convection, and evaporation. General anesthesia affects all aspects of thermoregulation by inhibiting responses like vasoconstriction and shivering that normally maintain core body temperature. This can lead to perioperative hypothermia if not prevented through measures like warmed fluids and surgical drapes.
Physiology of thermoregulation & monitering of temperatureSapan Jena
The document discusses human thermoregulation and the effects of anesthesia on the thermoregulatory system. It notes that anesthesia impairs normal thermoregulatory control by elevating warm-response thresholds and reducing cold-response thresholds, widening the interthreshold range. This makes inadvertent hypothermia more likely under anesthesia due to impaired defenses and heat loss to a cold operating room. The initial rapid decrease in core temperature during anesthesia is explained by redistribution of heat from the core to the periphery as anesthesia causes vasodilation and disrupts the normal core-peripheral temperature gradient.
Global warming is caused by increasing greenhouse gases from burning fossil fuels, which traps heat in the atmosphere. This is leading to rising sea levels, melting Arctic ice, and more extreme weather. While some argue impacts may be beneficial, others warn of severe economic costs from damage from hurricanes and needing to mitigate warming. Individual actions like using less energy and driving less can help reduce the problem.
Severe acute respiratory syndrome is caused by coronavirus, with an incubation period of 2-7 days but commonly 3-5 days. Children are rarely affected by SARS, which if not managed in time can cause death. The disease spread internationally.
This document discusses body temperature measurement. It describes the purposes of measuring body temperature as detecting fever, hypothermia, or hyperthermia. It also notes additional purposes like monitoring medicine effectiveness and planning pregnancy. The document outlines normal temperature ranges and describes common sites and types of thermometers for taking measurements, including mercury/glass, electronic/digital, chemical strips, infrared, and temporal artery thermometers. It provides steps for properly taking temperature with an infrared ear thermometer.
This document discusses temperature and how it is measured. It defines temperature as a measure of how hot or cold an object is compared to another object, and that heat flows from warmer objects to cooler ones. Temperature is typically measured using a thermometer. It describes three main temperature scales - Fahrenheit, Celsius, and Kelvin - and notes their reference points for water's freezing and boiling points. The document also provides examples of normal body temperature and room temperature in Celsius. It notes that temperatures above 40°C can be life-threatening, and above 50°C will cause immediate death. The highest recorded surviving human body temperature was 115.7°F (46.5°C), while the lowest recorded survival was 56.6
CSCR Agriculture Track w/ Larry Klotz: Weather or Not - Effects of Changing W...Sustainable Tompkins
Climate Smart & Climate Ready Conference Agriculture Track on April 19, 2013 at NYS Grange in Cortland, NY. Prof. Larry Klotz, SUNY Cortland. Weather or Not: Effects of Changing Weather on Local Agriculture. What is climate change? What are regional implications?
Body temperature is measured in degrees Celsius or Fahrenheit and normally ranges from 36-37.4°C orally. There are core and surface temperatures, with core being more constant near 37°C. Factors like basal metabolic rate, activity, and hormones influence heat production, while radiation, conduction, convection, and vaporization cause heat loss. Fever is a raised temperature over 37.5°C often caused by pyrogens like bacteria. Hypothermia is a lowered temperature below 35°C caused by exposure to cold. Nursing care for temperature issues focuses on monitoring, hydration, comfort measures, and antipyretic administration.
The document discusses thermoregulation and temperature monitoring. It summarizes that the hypothalamus regulates body temperature through heat production and loss mechanisms like radiation, conduction, convection, and evaporation. General anesthesia affects all aspects of thermoregulation by inhibiting responses like vasoconstriction and shivering that normally maintain core body temperature. This can lead to perioperative hypothermia if not prevented through measures like warmed fluids and surgical drapes.
Physiology of thermoregulation & monitering of temperatureSapan Jena
The document discusses human thermoregulation and the effects of anesthesia on the thermoregulatory system. It notes that anesthesia impairs normal thermoregulatory control by elevating warm-response thresholds and reducing cold-response thresholds, widening the interthreshold range. This makes inadvertent hypothermia more likely under anesthesia due to impaired defenses and heat loss to a cold operating room. The initial rapid decrease in core temperature during anesthesia is explained by redistribution of heat from the core to the periphery as anesthesia causes vasodilation and disrupts the normal core-peripheral temperature gradient.
Global warming is caused by increasing greenhouse gases from burning fossil fuels, which traps heat in the atmosphere. This is leading to rising sea levels, melting Arctic ice, and more extreme weather. While some argue impacts may be beneficial, others warn of severe economic costs from damage from hurricanes and needing to mitigate warming. Individual actions like using less energy and driving less can help reduce the problem.
Severe acute respiratory syndrome is caused by coronavirus, with an incubation period of 2-7 days but commonly 3-5 days. Children are rarely affected by SARS, which if not managed in time can cause death. The disease spread internationally.
Body temperature is regulated by balancing heat production and heat loss. The normal human body temperature ranges from 97-99°F orally and 36.1-37.2°C rectally. Temperature is precisely controlled through neural, vascular, behavioral and other physiological mechanisms. Fever is defined as a temperature above the normal range due to infection, illness or other causes, while hypothermia is a temperature below 35°C due to cold exposure or other factors. Nursing care focuses on monitoring temperature, providing supportive care and rewarming or cooling interventions as needed to maintain a normal temperature range.
The document argues that global warming is not man-made for several reasons: 1) Some scientists have signed petitions stating there is no evidence it is man-made; 2) Satellite data shows no trend in global temperature change; and 3) Computer models used to predict future temperatures are too crude to be accurate. It claims the sun, not human activity, is causing any warming and that governments and Al Gore have lied about or misrepresented data on topics like glaciers and polar bears for financial gain.
measurement of body temperature, fat and movementShafiu Gaya
This document discusses the measurement of body temperature, fat, and movement. It describes how body temperature is normally measured orally or rectally using a thermometer. It defines normal temperature as 37°C (98.6°F) and fever as above 38.3°C (101°F) rectally. The document also discusses measuring body fat using skin fold thickness and calipers at four body sites, and measuring body movement using goniometers to measure joint range of motion or accelerometers to monitor physical activity levels.
1. Humans tightly regulate their core body temperature around 37°C through feedback mechanisms involving thermal sensing receptors, central processing in the hypothalamus, and efferent responses like vasoconstriction and shivering.
2. During general anesthesia, thermoregulation is impaired as behavioral responses are removed and autonomic responses like shivering and vasoconstriction are decreased. This commonly leads to unintended hypothermia from heat loss exceeding the body's ability to generate heat.
3. Regional anesthesia also impairs thermoregulation by blocking cutaneous vasoconstriction and decreasing the shivering threshold, potentially resulting in hypothermia if not monitored. Active warming and other
Our body regulates its temperature through thermoregulation even when the external environment is cold or hot. When exposed to cold temperatures:
1. The hypothalamus causes blood vessels in the skin to narrow, restricting blood flow and reducing heat loss. It also stimulates muscles to shiver and generate heat.
2. As shown through an experiment where hand temperature and pulse were measured, exposure to cold caused rapid changes in pulse as the body circulated more blood and chemicals to maintain its temperature.
3. In cold conditions, one should wear warm clothing, eat spicy foods for heat generation, do light exercise, and warm up near heat sources to help the body regulate its temperature.
Temperature is a measurement of heat or cold expressed on a scale, with the most common scales being Celsius, Fahrenheit, and Kelvin. Celsius uses 0°C as the freezing point of water and 100°C as the boiling point. Fahrenheit uses 32°F and 212°F as these points. Kelvin uses 0K as absolute zero. Normal human body temperature is around 37°C or 98.6°F measured orally. Temperature is regulated by the hypothalamus and can be influenced by factors like exercise, age, and menstruation. Elevated temperature is a fever while lowered temperature is hypothermia.
This document discusses applying evidence-based medicine principles to mythical beasts. It reviews the evidence and recommendations for diagnosing and treating rhinosinusitis and unicorns. Rhinosinusitis is often misdiagnosed, with 80% of patients receiving unnecessary antibiotics. The evidence shows antibiotics only provide modest benefits for acute bacterial rhinosinusitis over symptomatic treatment. Unicorns are rarely seen and their diagnosis is difficult, while most reports indicate they are mostly harmless with treatment needs modest.
This document discusses various endocrine conditions including thyroid disorders, adrenal disorders, and their presentations and treatments.
Key points include:
- Hyperthyroidism is most commonly caused by Graves' disease and presents with tachycardia, tremors, and eye changes. Thyroid storm requires aggressive beta blockade, antithyroid medications, and treating any precipitants.
- Hypothyroidism is diagnosed using TSH levels. Myxedema coma requires supportive care and thyroid hormone replacement.
- Adrenal insufficiency presents differently depending on if it is primary or secondary. Primary causes low sodium, elevated potassium and low glucose while secondary causes low sodium and low glucose with normal potassium.
The document discusses the treatment of severe asthma exacerbations in the emergency department. It outlines several mainstay treatments including beta-2 agonists, ipratropium, and steroids. For patients not responding to initial treatments, it recommends considering magnesium, intravenous epinephrine, non-invasive positive pressure ventilation, or intubation. The document provides guidance on appropriate ventilator settings and treatments for potential complications of intubation like barotrauma. It concludes by listing additional resources on managing the crashing asthmatic patient.
This document discusses various topics related to cardiovascular drug toxicity, including:
1) Digoxin toxicity and its treatment with DigiFab fragments. Digoxin toxicity can cause various arrhythmias and the EKG may show conduction blocks.
2) Beta-blocker overdose treatment involves glucagon, insulin, and other inotropic support. High-dose insulin increases cardiac output by improving stroke volume rather than heart rate.
3) The EKG shows bidirectional ventricular tachycardia, a specific finding for digoxin toxicity. Intravenous lipid emulsion acts as a "sink" for lipid-soluble beta blockers and should be considered as a salvage treatment in massive overdoses.
Rabies caused by lyssavirus, transmitted via bites. In US, raccoons and bats most common carriers. Clinical stages include incubation, prodrome, neurological illness, death. Treatment includes wound washing, rabies immunoglobulin, vaccination.
Tick-borne illnesses discussed include Lyme disease caused by Borrelia burgdorferi transmitted by Ixodes ticks. It has 3 stages: localized rash, disseminated neuro/cardiac involvement, persistent arthritis. Rocky Mountain spotted fever caused by Rickettsia rickettsii transmitted by multiple tick species, seen in Southeast US. Symptoms include fever, rash. Ehrlichiosis and babesiosis cause malaria-like illness. Tulare
This document provides advice on career planning and job searching for emergency medicine physicians. It discusses important factors to consider such as location, compensation structure, work environment, equity and ownership opportunities. It warns of potential pitfalls like lack of tail coverage, delayed or vested retirement benefits, unclear ownership and compensation structures. It emphasizes the importance of asking questions about contracts, non-competes, incentive pay and fairness in benefits. The overall message is to carefully research potential jobs and consider your priorities to avoid common problems and set yourself up for long term career success and wealth building.
1) A 58-year-old man presented with a torn rotator cuff and received a brachial plexus block with bupivacaine and mepivacaine. He subsequently experienced two seizures and went into cardiac arrest.
2) Standard ACLS was unsuccessful for 20 minutes. Intravenous lipid emulsion (Intralipid) was then administered, which resulted in restoration of sinus rhythm within 15 seconds and detectable blood pressure.
3) Intralipid acts as a "lipid sink" to remove lipophilic drugs like bupivacaine from cardiac tissue and enhance their metabolism. It has been used successfully in numerous case reports of local anesthetic toxicity when standard ACLS fails
This document contains lecture slides from Dr. J.D. McCourt on various thoracic and respiratory topics. It includes practice questions, discussions of conditions like asthma, COPD, foreign body aspiration, and ARDS. For one practice question, the document indicates that an ABG with a pCO2 of 55 mmHg would indicate respiratory failure in a patient with COPD presenting with shortness of breath. It also provides overview information on the definitions, pathophysiology, presentations, treatments and more for several common pulmonary conditions.
In the 1950s, demand for emergency care skyrocketed as health insurance became more widely available and EDs began providing 24-hour coverage. However, care was inconsistent and unsafe due to a lack of specialized emergency physician training. The 1966 National Academy of Sciences report highlighted these issues and increased funding for emergency care. This led to the development of emergency medicine as a specialty, starting with the first emergency department staffed by trained physicians in Alexandria, Virginia in 1961. EMTALA was passed in 1986 to prevent patient dumping and ensure evaluation and treatment for emergency conditions regardless of ability to pay.
This document outlines Nathan Cleveland's framework for evidence-based practice in emergency medicine. It begins with disclaimers and goals, then covers epidemiology of poisonings in the US. The presentation emphasizes that the specific substance ingested is often unknown, but the clinical approach is similar - take a history, perform a physical exam looking for toxidromes, and order basic labs and tests like EKG, glucose, BMP, and potentially tox screens. Drug levels may provide some information, but the social history is also important. Management is based on stabilization and supportive care rather than specific antidotes in many cases.
This document discusses ankle and foot anatomy, mechanisms of injury, physical exam findings, radiology, and various ankle and foot injuries. It begins by covering key ankle and foot movements and mechanisms that can cause injuries like inversion, eversion, axial loading, and tendon stretching. Common injuries are then discussed including lateral malleolar fractures, ankle sprains, Achilles tendon ruptures, and more. Ottawa Ankle Rules and the use of standard ankle x-rays versus advanced imaging are reviewed. Specific fracture and injury findings on radiology are also summarized.
This document provides information on various topics related to hand injuries and conditions. It covers:
1. Nerve innervation, including the recurrent branch of the median nerve.
2. Common nerve palsies such as wrist drop, median nerve palsy, and ulnar nerve palsy.
3. Blood supply of the hand including the arteries and Allen's test.
4. Common bone injuries like metacarpal neck, shaft, and head fractures. Thumb fractures including Bennett's and Rolando fractures are also discussed.
5. Infections of the hand such as paronychia and felons.
6. Other topics like tendon injuries, metabolic
This document discusses explosives, improvised explosive devices (IEDs), and blast injuries. It begins by providing historical examples of bombings and notes that 70% of terrorist incidents involve conventional explosives. It then explains the explosion process and describes the shock wave and different phases. Primary blast injuries involve gas-containing organs and can include ruptured eardrums, lung injuries, and bowel injuries. Secondary injuries involve penetrating shrapnel and tertiary injuries include blunt trauma from being thrown. The document concludes by noting the massive destruction caused by suicide bombers and importance of understanding explosives and blast-related injuries.
This document discusses various gastrointestinal conditions including dysphagia, hiccups, esophageal rupture, pneumomediastinum, esophageal foreign bodies, food impaction, caustic ingestions, peptic ulcer disease, bilirubin, and hepatitis. It provides details on symptoms, diagnostic findings, treatment options, and complications for each condition. Key diagnostic tests mentioned include esophagram, endoscopy, and motility studies for dysphagia and chest x-ray for esophageal rupture or foreign bodies. Treatment depends on the specific condition but may include antibiotics, acid suppressants, anti-ulcer medications, endoscopy, or surgery.
This document provides an overview of common pediatric rashes and rashes that require emergent treatment. It begins by outlining the steps to evaluate a rash, including taking a history and performing a physical exam. Common rashes like scabies, acne, contact dermatitis, and atopic dermatitis are described. Emergent rashes discussed include Stevens-Johnson syndrome/toxic epidermal necrolysis, Neisseria meningitidis, measles, and Rocky Mountain spotted fever. Treatment options are provided for each discussed condition.
This document summarizes evidence-based management of upper respiratory infections. It begins with an overview of evidence-based medicine and establishes rules for risk-stratifying patients and aggressively treating symptoms. The majority of the document then focuses on specific upper respiratory conditions like the common cold, otitis media, sinusitis, pharyngitis, and bronchitis. For each condition, it discusses the evidence on etiology, microbiology, recommendations on antibiotic treatment or withholding, and complications to avoid. It emphasizes that most upper respiratory infections are viral in nature and do not require antibiotics. The document uses clinical case examples and trivia questions to engage learners.
Body temperature is regulated by balancing heat production and heat loss. The normal human body temperature ranges from 97-99°F orally and 36.1-37.2°C rectally. Temperature is precisely controlled through neural, vascular, behavioral and other physiological mechanisms. Fever is defined as a temperature above the normal range due to infection, illness or other causes, while hypothermia is a temperature below 35°C due to cold exposure or other factors. Nursing care focuses on monitoring temperature, providing supportive care and rewarming or cooling interventions as needed to maintain a normal temperature range.
The document argues that global warming is not man-made for several reasons: 1) Some scientists have signed petitions stating there is no evidence it is man-made; 2) Satellite data shows no trend in global temperature change; and 3) Computer models used to predict future temperatures are too crude to be accurate. It claims the sun, not human activity, is causing any warming and that governments and Al Gore have lied about or misrepresented data on topics like glaciers and polar bears for financial gain.
measurement of body temperature, fat and movementShafiu Gaya
This document discusses the measurement of body temperature, fat, and movement. It describes how body temperature is normally measured orally or rectally using a thermometer. It defines normal temperature as 37°C (98.6°F) and fever as above 38.3°C (101°F) rectally. The document also discusses measuring body fat using skin fold thickness and calipers at four body sites, and measuring body movement using goniometers to measure joint range of motion or accelerometers to monitor physical activity levels.
1. Humans tightly regulate their core body temperature around 37°C through feedback mechanisms involving thermal sensing receptors, central processing in the hypothalamus, and efferent responses like vasoconstriction and shivering.
2. During general anesthesia, thermoregulation is impaired as behavioral responses are removed and autonomic responses like shivering and vasoconstriction are decreased. This commonly leads to unintended hypothermia from heat loss exceeding the body's ability to generate heat.
3. Regional anesthesia also impairs thermoregulation by blocking cutaneous vasoconstriction and decreasing the shivering threshold, potentially resulting in hypothermia if not monitored. Active warming and other
Our body regulates its temperature through thermoregulation even when the external environment is cold or hot. When exposed to cold temperatures:
1. The hypothalamus causes blood vessels in the skin to narrow, restricting blood flow and reducing heat loss. It also stimulates muscles to shiver and generate heat.
2. As shown through an experiment where hand temperature and pulse were measured, exposure to cold caused rapid changes in pulse as the body circulated more blood and chemicals to maintain its temperature.
3. In cold conditions, one should wear warm clothing, eat spicy foods for heat generation, do light exercise, and warm up near heat sources to help the body regulate its temperature.
Temperature is a measurement of heat or cold expressed on a scale, with the most common scales being Celsius, Fahrenheit, and Kelvin. Celsius uses 0°C as the freezing point of water and 100°C as the boiling point. Fahrenheit uses 32°F and 212°F as these points. Kelvin uses 0K as absolute zero. Normal human body temperature is around 37°C or 98.6°F measured orally. Temperature is regulated by the hypothalamus and can be influenced by factors like exercise, age, and menstruation. Elevated temperature is a fever while lowered temperature is hypothermia.
This document discusses applying evidence-based medicine principles to mythical beasts. It reviews the evidence and recommendations for diagnosing and treating rhinosinusitis and unicorns. Rhinosinusitis is often misdiagnosed, with 80% of patients receiving unnecessary antibiotics. The evidence shows antibiotics only provide modest benefits for acute bacterial rhinosinusitis over symptomatic treatment. Unicorns are rarely seen and their diagnosis is difficult, while most reports indicate they are mostly harmless with treatment needs modest.
This document discusses various endocrine conditions including thyroid disorders, adrenal disorders, and their presentations and treatments.
Key points include:
- Hyperthyroidism is most commonly caused by Graves' disease and presents with tachycardia, tremors, and eye changes. Thyroid storm requires aggressive beta blockade, antithyroid medications, and treating any precipitants.
- Hypothyroidism is diagnosed using TSH levels. Myxedema coma requires supportive care and thyroid hormone replacement.
- Adrenal insufficiency presents differently depending on if it is primary or secondary. Primary causes low sodium, elevated potassium and low glucose while secondary causes low sodium and low glucose with normal potassium.
The document discusses the treatment of severe asthma exacerbations in the emergency department. It outlines several mainstay treatments including beta-2 agonists, ipratropium, and steroids. For patients not responding to initial treatments, it recommends considering magnesium, intravenous epinephrine, non-invasive positive pressure ventilation, or intubation. The document provides guidance on appropriate ventilator settings and treatments for potential complications of intubation like barotrauma. It concludes by listing additional resources on managing the crashing asthmatic patient.
This document discusses various topics related to cardiovascular drug toxicity, including:
1) Digoxin toxicity and its treatment with DigiFab fragments. Digoxin toxicity can cause various arrhythmias and the EKG may show conduction blocks.
2) Beta-blocker overdose treatment involves glucagon, insulin, and other inotropic support. High-dose insulin increases cardiac output by improving stroke volume rather than heart rate.
3) The EKG shows bidirectional ventricular tachycardia, a specific finding for digoxin toxicity. Intravenous lipid emulsion acts as a "sink" for lipid-soluble beta blockers and should be considered as a salvage treatment in massive overdoses.
Rabies caused by lyssavirus, transmitted via bites. In US, raccoons and bats most common carriers. Clinical stages include incubation, prodrome, neurological illness, death. Treatment includes wound washing, rabies immunoglobulin, vaccination.
Tick-borne illnesses discussed include Lyme disease caused by Borrelia burgdorferi transmitted by Ixodes ticks. It has 3 stages: localized rash, disseminated neuro/cardiac involvement, persistent arthritis. Rocky Mountain spotted fever caused by Rickettsia rickettsii transmitted by multiple tick species, seen in Southeast US. Symptoms include fever, rash. Ehrlichiosis and babesiosis cause malaria-like illness. Tulare
This document provides advice on career planning and job searching for emergency medicine physicians. It discusses important factors to consider such as location, compensation structure, work environment, equity and ownership opportunities. It warns of potential pitfalls like lack of tail coverage, delayed or vested retirement benefits, unclear ownership and compensation structures. It emphasizes the importance of asking questions about contracts, non-competes, incentive pay and fairness in benefits. The overall message is to carefully research potential jobs and consider your priorities to avoid common problems and set yourself up for long term career success and wealth building.
1) A 58-year-old man presented with a torn rotator cuff and received a brachial plexus block with bupivacaine and mepivacaine. He subsequently experienced two seizures and went into cardiac arrest.
2) Standard ACLS was unsuccessful for 20 minutes. Intravenous lipid emulsion (Intralipid) was then administered, which resulted in restoration of sinus rhythm within 15 seconds and detectable blood pressure.
3) Intralipid acts as a "lipid sink" to remove lipophilic drugs like bupivacaine from cardiac tissue and enhance their metabolism. It has been used successfully in numerous case reports of local anesthetic toxicity when standard ACLS fails
This document contains lecture slides from Dr. J.D. McCourt on various thoracic and respiratory topics. It includes practice questions, discussions of conditions like asthma, COPD, foreign body aspiration, and ARDS. For one practice question, the document indicates that an ABG with a pCO2 of 55 mmHg would indicate respiratory failure in a patient with COPD presenting with shortness of breath. It also provides overview information on the definitions, pathophysiology, presentations, treatments and more for several common pulmonary conditions.
In the 1950s, demand for emergency care skyrocketed as health insurance became more widely available and EDs began providing 24-hour coverage. However, care was inconsistent and unsafe due to a lack of specialized emergency physician training. The 1966 National Academy of Sciences report highlighted these issues and increased funding for emergency care. This led to the development of emergency medicine as a specialty, starting with the first emergency department staffed by trained physicians in Alexandria, Virginia in 1961. EMTALA was passed in 1986 to prevent patient dumping and ensure evaluation and treatment for emergency conditions regardless of ability to pay.
This document outlines Nathan Cleveland's framework for evidence-based practice in emergency medicine. It begins with disclaimers and goals, then covers epidemiology of poisonings in the US. The presentation emphasizes that the specific substance ingested is often unknown, but the clinical approach is similar - take a history, perform a physical exam looking for toxidromes, and order basic labs and tests like EKG, glucose, BMP, and potentially tox screens. Drug levels may provide some information, but the social history is also important. Management is based on stabilization and supportive care rather than specific antidotes in many cases.
This document discusses ankle and foot anatomy, mechanisms of injury, physical exam findings, radiology, and various ankle and foot injuries. It begins by covering key ankle and foot movements and mechanisms that can cause injuries like inversion, eversion, axial loading, and tendon stretching. Common injuries are then discussed including lateral malleolar fractures, ankle sprains, Achilles tendon ruptures, and more. Ottawa Ankle Rules and the use of standard ankle x-rays versus advanced imaging are reviewed. Specific fracture and injury findings on radiology are also summarized.
This document provides information on various topics related to hand injuries and conditions. It covers:
1. Nerve innervation, including the recurrent branch of the median nerve.
2. Common nerve palsies such as wrist drop, median nerve palsy, and ulnar nerve palsy.
3. Blood supply of the hand including the arteries and Allen's test.
4. Common bone injuries like metacarpal neck, shaft, and head fractures. Thumb fractures including Bennett's and Rolando fractures are also discussed.
5. Infections of the hand such as paronychia and felons.
6. Other topics like tendon injuries, metabolic
This document discusses explosives, improvised explosive devices (IEDs), and blast injuries. It begins by providing historical examples of bombings and notes that 70% of terrorist incidents involve conventional explosives. It then explains the explosion process and describes the shock wave and different phases. Primary blast injuries involve gas-containing organs and can include ruptured eardrums, lung injuries, and bowel injuries. Secondary injuries involve penetrating shrapnel and tertiary injuries include blunt trauma from being thrown. The document concludes by noting the massive destruction caused by suicide bombers and importance of understanding explosives and blast-related injuries.
This document discusses various gastrointestinal conditions including dysphagia, hiccups, esophageal rupture, pneumomediastinum, esophageal foreign bodies, food impaction, caustic ingestions, peptic ulcer disease, bilirubin, and hepatitis. It provides details on symptoms, diagnostic findings, treatment options, and complications for each condition. Key diagnostic tests mentioned include esophagram, endoscopy, and motility studies for dysphagia and chest x-ray for esophageal rupture or foreign bodies. Treatment depends on the specific condition but may include antibiotics, acid suppressants, anti-ulcer medications, endoscopy, or surgery.
This document provides an overview of common pediatric rashes and rashes that require emergent treatment. It begins by outlining the steps to evaluate a rash, including taking a history and performing a physical exam. Common rashes like scabies, acne, contact dermatitis, and atopic dermatitis are described. Emergent rashes discussed include Stevens-Johnson syndrome/toxic epidermal necrolysis, Neisseria meningitidis, measles, and Rocky Mountain spotted fever. Treatment options are provided for each discussed condition.
This document summarizes evidence-based management of upper respiratory infections. It begins with an overview of evidence-based medicine and establishes rules for risk-stratifying patients and aggressively treating symptoms. The majority of the document then focuses on specific upper respiratory conditions like the common cold, otitis media, sinusitis, pharyngitis, and bronchitis. For each condition, it discusses the evidence on etiology, microbiology, recommendations on antibiotic treatment or withholding, and complications to avoid. It emphasizes that most upper respiratory infections are viral in nature and do not require antibiotics. The document uses clinical case examples and trivia questions to engage learners.
This document provides an overview of evidence-based management of skin and soft tissue infections (SSTIs). It begins with brief historical quotes related to SSTIs. The main topics covered include: types and classification of SSTIs; challenges in determining causative organisms due to lack of cultures/biopsies; and current guidelines from CDC and IDSA for diagnosis and treatment. Throughout, it emphasizes the need for evidence-based approaches and highlights gaps where more research is still needed.
Taylor post-exercise cooling to treat heat injuryJA Larson
1) Eight male subjects were heated to an esophageal temperature of 39.5°C and then cooled using three methods: air cooling at 20-22°C, cold water immersion at 14°C, and temperate water immersion at 26°C.
2) Cooling times to reach an esophageal temperature of 37.5°C were significantly faster for both water immersion methods (2-3 minutes) compared to air cooling (23 minutes).
3) The time to cool in temperate water was only marginally longer than in cold water (45 seconds difference), which was deemed clinically insignificant.
This document discusses hypothermia, including its definition, causes, effects on organ systems, identification, and treatment approaches. Key points include: 1) Hypothermia is defined as a core body temperature below 96.8°F and can be mild, moderate, or severe; 2) It is caused by increased heat loss or decreased heat production and impacts organ systems like the heart, brain, and kidneys; 3) Identification requires measuring low rectal temperature with a specialized thermometer and gentle patient handling; 4) Treatment aims to rewarm the body slowly through passive warming and may involve invasive approaches for severe hypothermia to avoid complications like afterdrop.
Cooling Firefighters With Arm Cooling StationsJA Larson
This study compared the effectiveness of cooling hyperthermic firefighters by immersing their forearms and hands in 10°C and 20°C water. Six male firefighters wore heavy gear during exercise bouts in hot conditions, then removed gear during rest. Immersing just hands in 20°C water did not lower core temperature, but adding forearm immersion did. Immersing hands and forearms in 10°C water lowered core temperature most. Adding forearm immersion enhances cooling more than hands alone, with lower water temperatures providing better cooling.
Major Chaken Maniyan provides an outline on heat regulation physiology, classifications of heat-related injuries, cooling methods, management of complications, and new interventions. The document discusses heat transfer mechanisms, signs and symptoms of heat-related illnesses ranging from mild to severe including heat rash, heat edema, heat syncope, heat cramps, heat exhaustion, and heat stroke. Cooling techniques like ice water immersion and evaporative cooling are presented, as well as treatments for complications of heat stroke such as renal failure, rhabdomyolysis, and electrolyte abnormalities. Risk factors, pathogenesis, and organ dysfunction in heat stroke are also reviewed.
This document discusses a case of a 45-year-old male presenting with toe pain secondary to gout who had an IV placed with subsequent air embolism due to failure to flush the IV tubing. It prompts for the diagnosis and treatment. Air embolism would be the diagnosis, and treatment would involve placing the patient in left lateral decubitus position and administering 100% oxygen via non-rebreather mask to reduce the size of the air bubbles and support oxygenation. The document goes on to discuss various topics relating to hyperbaric oxygen therapy including its physics, physiology, indications, disadvantages, evidence for use in emergency medicine, and reimbursement issues.
This document summarizes human physiological adaptations to acute cold exposure. It outlines behavioral adaptations like clothing use and physiological adaptations including cutaneous vasoconstriction, increased metabolism, and shivering. The metabolic adaptations help generate heat through processes like shivering thermogenesis and non-shivering thermogenesis in brown adipose tissue. Certain groups like the elderly or those under the influence of drugs may have reduced ability to adapt to cold.
The document summarizes the physiological effects of hydrotherapy and clay therapy. It discusses how hydrotherapy uses water in different forms and temperatures to promote health and treat diseases. It covers the properties of water and how temperature, duration, application site, and other factors affect the physiological impacts. Key effects on the skin, respiratory system, circulatory system, musculoskeletal system, and blood are outlined. The document provides references to studies that have examined various physiological impacts.
The document discusses mechanisms of body temperature regulation and abnormalities of thermal regulation. It explains that the hypothalamus helps maintain a constant core temperature between 36-37°C despite changes in heat production and the environment. Temperature is regulated through vasodilation, sweating, shivering and other mechanisms in response to heat and cold exposure. Prolonged heat or cold exposure can cause the body to adapt through increased sweating or non-shivering thermogenesis. Abnormalities include heat stroke from excessive heat, hypothermia from cold exposure, and fever caused by pyrogens raising the temperature.
Thermoregulation [compatibility mode] (1)mohd ahmad
The document discusses thermoregulation and the physiological responses to exercise in heat and cold. It describes the mechanisms of heat loss from the body through conduction, convection, radiation, and evaporation. It explains how the hypothalamus acts as the body's thermostat to regulate temperature through cutaneous vasodilation and sweating in heat, and cutaneous vasoconstriction and shivering in cold. During exercise in heat, cardiovascular function is challenged and energy production increases to maintain homeostasis through increased sweating and blood flow to the skin.
- The study compared endovascular cooling using femoral devices versus basic external cooling with fans, tents and ice packs for targeted temperature management after out-of-hospital cardiac arrest.
- The primary outcome of survival without major neurological damage at 28 days did not significantly differ between the endovascular and external cooling groups. Improvement in this outcome at 90 days also did not reach significance for endovascular cooling.
- However, endovascular cooling achieved the target temperature of 33C significantly faster and maintained the target temperature more strictly than external cooling. Minor side effects related to the cooling method were also more frequent with endovascular cooling.
Hyperthermic syndrome in ICU and their management.pptxNeurologyKota
Based on the information provided, this patient is likely experiencing malignant hyperthermia (MH). Key signs include:
- Muscle rigidity developing post-operatively
- Increasing tachycardia, tachypnea, and rising temperature shortly after being admitted to PACU
- Recent exposure to inhalational anesthetic triggers for MH like halothane during surgery
The immediate steps in management should be:
1. Discontinue any triggering anesthetic agents
2. Administer dantrolene sodium 2-3 mg/kg IV to reduce calcium release and muscle rigidity
3. Initiate cooling measures and monitor for signs of multiple organ dysfunction as temperature rises further
Prompt diagnosis and
Environmental influence on performance Sukanya1411
This document discusses how environmental factors like temperature, altitude and humidity can influence human performance. It covers the body's thermoregulation processes for maintaining core temperature during cold and heat exposure. During cold, the body increases heat production and conservation through vascular, muscular and hormonal adjustments. During heat, the main mechanisms of heat loss are radiation, conduction, convection and evaporation. Acclimatization to altitude involves both immediate and long-term adaptations to the reduced oxygen levels to improve tolerance. The key factors for exercising in heat and cold are maintaining hydration and avoiding large fluctuations in core temperature.
This document provides an overview of cryosurgery. It discusses the history and development of cryosurgery using extreme cold, particularly liquid nitrogen, to destroy diseased tissue. The document outlines the cryosurgery procedure for conditions like prostate cancer, which involves inserting cryoprobes under ultrasound guidance to create ice balls to destroy the tumor. It explains how cryosurgery works through immediate and delayed cell destruction caused by rapid freezing and slow thawing. The document emphasizes the importance of using the lowest possible temperatures, rapid cooling and slow thawing to maximize the effectiveness of cryosurgery.
Heat stroke is a severe heat-related illness that occurs when the body becomes unable to regulate its core temperature, causing it to rise rapidly. There are two main types - exertional heat stroke, which affects young active individuals, and classic nonexertional heat stroke, which more commonly affects elderly or ill people. Heat stroke is life-threatening and can cause damage to organs and death if not promptly treated. Factors that contribute to heat stroke include increased heat production from physical exertion or medical conditions, reduced ability to dissipate heat through sweating or blood flow, and an inability to acclimate to hot environments.
This document discusses therapeutic hypothermia for patients who experience cardiac arrest. Lowering a patient's core body temperature to 32-34°C for 12-24 hours after resuscitation can improve outcomes by reducing neurological injury from reperfusion. Clinical studies show increased survival rates and neurological function for patients who receive therapeutic hypothermia. The document reviews different methods for inducing and maintaining therapeutic hypothermia, as well as barriers to implementing these protocols more widely. It advocates for the establishment of specialized cardiac arrest centers to optimize post-cardiac arrest care.
This document discusses various topics related to thermoregulation including types of temperature, factors affecting thermoregulation, fever, hyperthermia, hypothermia, and frostbite. It defines these conditions and discusses their causes, signs and symptoms, diagnosis, and management. Nursing considerations are provided for assessment and care of patients experiencing fever, hyperthermia, and hypothermia. Current trends in cooling techniques for hyperthermia are also reviewed.
Cryotherapy and its implications in Oral surgeryShibani Sarangi
Cryosurgery involves applying low temperatures to living tissues in a controlled manner to induce irreversible damage. It has been used for over 100 years to treat skin lesions. The document discusses the history, indications, contraindications, cryogens, and mechanisms of cryosurgery. It describes open systems using liquid nitrogen spray and closed systems using cryoprobes. Cryosurgery can treat premalignant and benign oral lesions using 1-2 minute freeze/thaw cycles and is an effective minimally invasive treatment option in oral and maxillofacial surgery.
Exercising in hot and cold environments can have different effects on the body. It's important to consider factors like hydration, clothing, and duration of exercise when working out in extreme temperatures.
The document provides information on thermoregulation and illnesses related to heat and cold exposure. It discusses the normal mechanisms of heat loss and gain and how they are affected by hot and cold environments. Various minor and major heat-related illnesses like heat rash, heat exhaustion and heat stroke are described. The risks, signs, symptoms and management of these conditions are outlined. Cold-related injuries like frostbite and hypothermia are also summarized, including treatments like gradual rewarming. Investigations for hypothermia and approaches for mild versus severe hypothermia are highlighted.
This document discusses sickle cell crises, which are medical emergencies that can occur in people with sickle cell disease. It describes the four main types of sickle cell crises: splenic sequestration crisis, hemolytic crisis, aplastic crisis, and vaso-occlusive crisis. The vaso-occlusive crisis, where abnormal sickle cells get stuck in small blood vessels and cut off blood flow, is the most common cause of complications in sickle cell disease and can cause pain all over the body. The document provides some details on the signs, symptoms, and treatments for each type of sickle cell crisis.
This document provides an overview of gallbladder disease, including evaluation and treatment options. It discusses common conditions like cholelithiasis (gallstones), choledocholithiasis (gallstones in the common bile duct), cholecystitis (inflammation of the gallbladder), and cholangitis (infection of the biliary tree). Diagnostic tools like ultrasound and treatments including medications, ERCP, and cholecystectomy are covered. Rare and serious conditions such as emphysematous cholecystitis are also mentioned. The goal is to improve understanding of disease pathology and presentation, diagnostic modalities, and treatment options.
This document discusses accountable care organizations (ACOs) and how to advocate for emergency medicine. It notes that the current fee-for-service model is unsustainable and that ACOs aim to realign financial incentives to improve cost efficiency and outcomes. It encourages physicians to get involved in advocacy and provides tips on finding an issue one is passionate about, becoming informed on the issues, and establishing contact with elected officials through various means like mail, email, telephone, testifying, and social media. Advocacy is part of physicians' ethical duty to promote public health.
The document discusses the history and types of chemical warfare agents, including their qualities and classes such as nerve agents, asphyxiants, vesicants, choking agents, and tearing agents. It describes the signs and symptoms of exposure to these agents as well as their management, which involves personal protection, decontamination, supportive care, and specific antidotes for some agents like nerve gases and cyanide poisoning. The document also references the use of chemical weapons in past wars and recent conflicts like the Syrian civil war.
1. The document discusses various bioterrorism agents that can cause pulmonary disease, categorized from A to C based on their ability to be disseminated and cause public health impact.
2. Category A agents like anthrax, plague, and smallpox are easily disseminated and can result in high mortality. Category B agents include Q fever and psittacosis, which are less easily disseminated. Category C includes influenza and SARS.
3. For each agent, the document reviews their microbiology, clinical presentations, diagnosis, and treatment recommendations to help clinicians maintain a high index of suspicion for these diseases.
A 51-year-old female presented with weakness and isolated syncope. She was found to be bradycardic with a heart rate in the 30s-40s. Despite treatment, she remained persistently altered. Initial labs and imaging were normal except for a slightly elevated temperature. She was diagnosed with myxedema coma based on highly elevated TSH and undetectable T3 and T4 levels. Treatment with intravenous levothyroxine improved her mental status.
This document outlines an approach for implementing evidence-based medicine (EBM) in the emergency department. It begins by defining EBM and explaining its principles. It then discusses both the reasons for and criticisms of practicing EBM. The document proposes a multi-step process for applying EBM that involves formulating a focused clinical question, searching the literature, appraising the evidence, and applying it to individual patients. It acknowledges barriers to practicing EBM but provides specific resources and recommends cultivating a culture of evidence-based practice to help overcome these barriers. The overall goal is to provide a framework for incorporating the best available research evidence into clinical decision-making in the emergency department.
The Pneumonia Severity Index (PSI) was developed in 1989 based on a cohort study of 38,000 patients to stratify pneumonia patients into risk classes based on history, exam findings, and labs. It was later validated and expanded by the PORT research team. The PSI uses a two-step scale, with step one identifying very low risk patients based on age, vital signs, and medical history. Higher risk classes have higher mortality rates. Several other scoring systems have been developed, including CURB-65, but meta-analyses found PSI/PORT to be the most sensitive while CURB-65 is more specific. The tools can help identify low risk patients and guide discussions about inpatient versus outpatient
The 10 Most Influential Leaders Guiding Corporate Evolution, 2024.pdfthesiliconleaders
In the recent edition, The 10 Most Influential Leaders Guiding Corporate Evolution, 2024, The Silicon Leaders magazine gladly features Dejan Štancer, President of the Global Chamber of Business Leaders (GCBL), along with other leaders.
Recruiting in the Digital Age: A Social Media MasterclassLuanWise
In this masterclass, presented at the Global HR Summit on 5th June 2024, Luan Wise explored the essential features of social media platforms that support talent acquisition, including LinkedIn, Facebook, Instagram, X (formerly Twitter) and TikTok.
Discover timeless style with the 2022 Vintage Roman Numerals Men's Ring. Crafted from premium stainless steel, this 6mm wide ring embodies elegance and durability. Perfect as a gift, it seamlessly blends classic Roman numeral detailing with modern sophistication, making it an ideal accessory for any occasion.
https://rb.gy/usj1a2
Understanding User Needs and Satisfying ThemAggregage
https://www.productmanagementtoday.com/frs/26903918/understanding-user-needs-and-satisfying-them
We know we want to create products which our customers find to be valuable. Whether we label it as customer-centric or product-led depends on how long we've been doing product management. There are three challenges we face when doing this. The obvious challenge is figuring out what our users need; the non-obvious challenges are in creating a shared understanding of those needs and in sensing if what we're doing is meeting those needs.
In this webinar, we won't focus on the research methods for discovering user-needs. We will focus on synthesis of the needs we discover, communication and alignment tools, and how we operationalize addressing those needs.
Industry expert Scott Sehlhorst will:
• Introduce a taxonomy for user goals with real world examples
• Present the Onion Diagram, a tool for contextualizing task-level goals
• Illustrate how customer journey maps capture activity-level and task-level goals
• Demonstrate the best approach to selection and prioritization of user-goals to address
• Highlight the crucial benchmarks, observable changes, in ensuring fulfillment of customer needs
Implicitly or explicitly all competing businesses employ a strategy to select a mix
of marketing resources. Formulating such competitive strategies fundamentally
involves recognizing relationships between elements of the marketing mix (e.g.,
price and product quality), as well as assessing competitive and market conditions
(i.e., industry structure in the language of economics).
At Techbox Square, in Singapore, we're not just creative web designers and developers, we're the driving force behind your brand identity. Contact us today.
Anny Serafina Love - Letter of Recommendation by Kellen Harkins, MS.AnnySerafinaLove
This letter, written by Kellen Harkins, Course Director at Full Sail University, commends Anny Love's exemplary performance in the Video Sharing Platforms class. It highlights her dedication, willingness to challenge herself, and exceptional skills in production, editing, and marketing across various video platforms like YouTube, TikTok, and Instagram.
Part 2 Deep Dive: Navigating the 2024 Slowdownjeffkluth1
Introduction
The global retail industry has weathered numerous storms, with the financial crisis of 2008 serving as a poignant reminder of the sector's resilience and adaptability. However, as we navigate the complex landscape of 2024, retailers face a unique set of challenges that demand innovative strategies and a fundamental shift in mindset. This white paper contrasts the impact of the 2008 recession on the retail sector with the current headwinds retailers are grappling with, while offering a comprehensive roadmap for success in this new paradigm.
Industrial Tech SW: Category Renewal and CreationChristian Dahlen
Every industrial revolution has created a new set of categories and a new set of players.
Multiple new technologies have emerged, but Samsara and C3.ai are only two companies which have gone public so far.
Manufacturing startups constitute the largest pipeline share of unicorns and IPO candidates in the SF Bay Area, and software startups dominate in Germany.
Structural Design Process: Step-by-Step Guide for BuildingsChandresh Chudasama
The structural design process is explained: Follow our step-by-step guide to understand building design intricacies and ensure structural integrity. Learn how to build wonderful buildings with the help of our detailed information. Learn how to create structures with durability and reliability and also gain insights on ways of managing structures.
Navigating the world of forex trading can be challenging, especially for beginners. To help you make an informed decision, we have comprehensively compared the best forex brokers in India for 2024. This article, reviewed by Top Forex Brokers Review, will cover featured award winners, the best forex brokers, featured offers, the best copy trading platforms, the best forex brokers for beginners, the best MetaTrader brokers, and recently updated reviews. We will focus on FP Markets, Black Bull, EightCap, IC Markets, and Octa.
IMPACT Silver is a pure silver zinc producer with over $260 million in revenue since 2008 and a large 100% owned 210km Mexico land package - 2024 catalysts includes new 14% grade zinc Plomosas mine and 20,000m of fully funded exploration drilling.
Best practices for project execution and deliveryCLIVE MINCHIN
A select set of project management best practices to keep your project on-track, on-cost and aligned to scope. Many firms have don't have the necessary skills, diligence, methods and oversight of their projects; this leads to slippage, higher costs and longer timeframes. Often firms have a history of projects that simply failed to move the needle. These best practices will help your firm avoid these pitfalls but they require fortitude to apply.
Zodiac Signs and Food Preferences_ What Your Sign Says About Your Tastemy Pandit
Know what your zodiac sign says about your taste in food! Explore how the 12 zodiac signs influence your culinary preferences with insights from MyPandit. Dive into astrology and flavors!
13. MORTALITY HEAT ILLNESSOBJECTIVES
Leon LR, Helwig BG. Heat stroke: Role of the systemic inflammatory response. J Appl Physiol 2010;109:1980-8.
HEAT STROKE
Mortality rate?
21-63%
14. HEAT ILLNESS MANAGEMENTHYPERTHERMIA
Khosla R, Guntupalli KK. Heat-related illnesses. Crit Care Clin 1999;15:251-63
HEAT-RELATED
ILLNESS
End-organ Dysfunction = “Heatstroke”
15. MANAGEMENT HEAT STROKEHEAT ILLNESS
Bouchama A, Knochel JP. Heat Stroke. N Engl J Med 2002;346:1978-88
Supportive
Care
Rapid
Cooling
MANAGEMENT
16. HEAT STROKE HEAT BALANCEMANAGEMENT
Bouchama A, Knochel JP. Heat Stroke. N Engl J Med 2002;346:1978-88
HEAT STROKE
CLASSIC EXERTIONAL
17. HEAT BALANCE CONDUCTIONHEAT STROKE
Lugo-Amador NM, Rothenhaus T, Moyer P. Heat-related illness. Emerg Med Clin N Am 2004;22:315-27.
HEAT BALANCE
HEAT
IN
HEAT
OUT
RADIATION
TEMPERATURE
METABOLISM RADIATION
CONVECTION
CONDUCTION
EVAPORATION
18. CONDUCTION EVAPORATIONHEAT BALANCE
Lugo-Amador NM, Rothenhaus T, Moyer P. Heat-related illness. Emerg Med Clin N Am 2004;22:315-27.
HEAT BALANCE
HEAT
IN
HEAT
OUT
RADIATION
TEMPERATURE
METABOLISM RADIATION
CONVECTION
EVAPORATION
X
CONDUCTION
20. CONDUCTION
CONDUCTION
Ice Packs
Kielblock AJ, Van Rensburg
JP, Franz RM. Body cooling as a
method for reducing hyperthermia:
An evaluation of techniques.
S Afr Med J 1986; 69:378-80
EVAPORATION CONVECTION
25. SUMMARY
SUMMARY NEW IDEASCONVECTION
Immersion 0.2-0.35 ⁰C/min
Water+Fans 0.15-0.25 ⁰C/min
Dousing + Ice Massage 0.2 ⁰C/min
Cool IV Fluid 0.015-0.076 ⁰C/min
Ice Packs 0.028-0.034 ⁰C/min
Fan Alone 0.02-0.04 ⁰C/min
Casa DJ, et al. Cold water immersion: the gold standard for heat stroke treatment. Exerc Sport Sci Rev 2007;35:141-9.
26. NEW IDEAS TAKE HOMESUMMARY
Acad Emerg Med 2001;17:360-7.
FUTURE DIRECTIONS
Cooling Blankets / Garments
27. TAKE HOME THE ENDNEW IDEAS
FUTURE DIRECTIONS
Metabolism - Intubation
28. J Parenter Enteral Nutr. 2003;27:27-35.
FUTURE DIRECTIONS
Metabolism - Paralysis
TAKE HOME THE ENDNEW IDEAS
Hi, my name is Nathan Cleveland and today I would like to talk to you about the patient who arrives in your ED ‘hot as hell’ and what the evidence tells us about managing heatstroke patients.
But first, let me say, “welcome to Las Vegas.” I’m not just here for this conference. I actually live and work in this town at University Medical Center just between here and downtown. As you would expect, emergency medicine here is pretty glamorous. But we do see a lot of what you would expect to see in a hot desert environment.
Things like…
And…
And of course… Believe me, I couldn’t make this stuff up if I tried. These are all real chief complaints from our electronic tracking board.
But what I really want to talk to you about today, is the patient who comes in hot. Because unlike ‘falling off a stripper pole,’ ‘being sad that Michael Jackson died’ or ‘waking up naked next to your bike at the pig farm’ – ‘hot’ kills.
I was working an afternoon shift back in August of last year when this man was brought in to the department. A 34yo Hispanic male landscaper with no health problems, on no medications and with no reported history of drug abuse. His friends stated that he was ‘tired all day’ and ‘quieter than normal.’ Then when they were walking back to their truck at the end of a job, he fell to the ground unresponsive. EMS arrived and transported the patient. En route, he began seizing. When arrived to the ED, he was no longer seizing but had a GCS score of 6 and was immediately intubated.
Although it is hard to read, this was the initial core temperature we recorded – 109.2. For any of you not from the United States, Belize or Palau, that’s 42.9 C
Three weeks later, a 42yo female with a history of methamphetamine abuse was found unconscious next to a bus stop. As I said, it’s a pretty glamorous place… No additional information about medications or recent drug abuse could be obtained. She also arrived to the department obtunded and required immediate intubation.
This is even a little harder to read, but her initial core temperature was 107.1. Again, for the very educated, that’s 41.7 C
Since we are the premier academic and tertiary care hospital in southern Nevada, I of course used our cutting edge and high-tech cooling equipment. Namely, a cafeteria cart full of buckets of ice and an industrial fan. Unfortunately the male patient never even made it out of the emergency department and died of cardiovascular collapse approximately 2.5 hours after arrival. The female patient was admitted to the ICU, but ultimately died prior to hospital discharge. Maybe these patients’ fates were sealed before they arrived in my department, but I had a very difficult time adequately cooling either of these patients and I began to wonder whether I really knew what the current best available literature was regarding rapid cooling of heatstroke patients.
I really only have two objectives for this short talk. First, I want to briefly define the heatstroke problem. Second, I want to go to the literature to identify the best practices for management of heatstroke and try to provide you with some strategies to take back to your shop.
So, let’s talk about heat stroke mortality. Who here thinks the mortality rate for patients arrive with a temp greater than 40 C is 0-5%? 5-10%? 10-15%? 15-20% Anyone think it’s over 20%??... 21-63%!!! Are you kidding me? The mortality from heat stroke is remarkably high! With the exception of cardiac arrest, I can’t think of many emergency conditions with that high of a mortality rate. This is unacceptable. And this mortality is due to multi-organ system failure. Heatstroke can cause dysfunction to almost every system and common findings include… AMS, Sz, renal failure, CHF, ARDS, DIC, electrolyte abnormalities, dysrhythmias, rhabdomyolysis, etc., etc.
I do just want to briefly mention terminology here. Obviously, when apt is found to be hotter than they should be, you have to consider a broad differential for that hyperthermia. But once you have established that you are dealing with hyperthermia as a result of environmental or exertional factors, there is always a lot of discussion about the correct terminology. Is it “heat cramps,” “heat exhaustion,” “sun stroke” or “heat stroke?” Well, Vegas is a food-crazy town, so let’s use a food analogy. Think of it as degrees of doneness like a steak which ranges from rare to well-done. The only point on this spectrum that you need to know is that when you have evidence of end-organ dysfunction, the patient is classified as having “heat stroke” and the aggressiveness of your care needs to be escalated.
When it comes to management, you really only have 2 options. I’m going to assume that you are all experts in supportive care – things like intubation and mechanical ventilation, controlling seizures, correcting electrolyte abnormalities, etc. so we will focus on what the literature says about rapid cooling.
Historically, there has been a focus on dividing heat stroke into two types. Classic heatstroke is seen in elderly, obese and psychiatric patients who have comorbid disease. Essentially, these are people who have difficulty removing themselves from the hot environment.Exertional heat stroke, on the other hand, occurs in young and otherwise healthy patients. Frequently athletes, military recruits and manual laborers. This distinction is irrelevant – since heat stroke is all about the heat balance…
There are two external sources of heat: radiation from the sun, and the ambient temperature if that temperature is greater than the patient’s core temperature – these are both big contributors in an environment like Las Vegas. Metabolism however, is the biggest source of heat – after all, we’re warm-blooded creatures and we have been designed to create heat. There are 4 ways to dissipate heat: evaporation – which is facilitated by sweating and the large surface area of our skin, but also occurs with respiration; radiation – is a relatively small contributor to heat loss; conduction – which requires contact with a cooler object such as an icepack; and convection – which can be thought of as conduction to the air immediately around us, followed by removal of that air by wind.
Assuming the patient is already in your department, they have been removed from the radiation of the sun and the hot environment. That leaves you with these five processes by which you can attempt to cool the patient. Unfortunately there is little you can do to increase the negligible amount of heat lost via radiation. Let’s look at what the literature says about cooling via each of these mechanisms.
Strategy #1 is cold-water immersion. Who has heard that cold water immersion can actually paradoxically RAISE core temperature due to peripheral vasoconstriction? Turns out that that is not true. Two separate systematic reviews have found that cold water immersion leads to the most rapid decrease in core body temperature – approaching 1/3 degree Celsius per minute. The biggest problem with water immersion is that very few of us have tubs in our departments and placing an altered or obtunded pt in cold water makes supportive care very difficult.
Ice packs have usually been studied in conjunction with other methods, however, one study looked at ice packs alone. They found cooling rates between 0.028-0.034 C/min.
Cold IV fluids have been studied in the setting of heat stroke as well as in induced therapeutic hypothermia. I consider this to be an example of conductive cooling as well and numerous studies have shown cooling rates on the order of 0.015-0.076 C/min
What about my strategy of mist or water dousing? When I was in residency I remember being taught that this was the most rapid way to cool a patient. Much of this early work was performed by a Dr. Khogali in the middle east but more recent studies have confirmed that keeping the skin moist in order to increase evaporation can cool the pt up 0.076 C/min. I especially like this study which combined water dousing (evaporative cooling) with ice massage (conductive cooling) and found cooling rates close to 70% as rapid as water immersion.
What about fans alone (convection without evaporation)? Well, it’s relatively ineffective – the fact that it hasn’t really been studies since 1959 tells you something. The only recent study actually used a helicopter downdraft as the fan – which I can’t entirely endorse. Rates are in the 0.02-0.04 C/min.
But when you combine the two previous strategies - fans (convection) with mist or water dousing (evaporation) you get much-improved cooling rates of around 0.15-0.25 C/min.
With the advent of therapeutic hypothermia protocols, many of us have these devices in our departments. I am a big fan of using these in a modified way in the hyperthermicpatient. Let me explain why. With traditional cooling strategies like mist and fans, ice massage or ice packs, almost 50% of the patient’s surface area is in contact with the hospital bed and is actually well-insulated. Since we can’t hang the patient from the ceiling, I advocate placing cooling blankets or garments under the patient. This strategy has not been studies in heat stroke patients but we know from the therapeutic hypothermia literature that…
Often your severely hyperthermic patient will need intubation for airway protection. But there is an additional theoretical reason for considering mechanical ventilation. The work of breathing itself contributes about 5-10% of our basal metabolic rate. We are unable to influence the majority of processes contributing to BMR - but we can decrease the work of breathing. This has not been studied in heat stroke but I believe it is worth looking into in the future.
What about using neuromuscular blocking agents to decrease the heat generated by metabolism. Numerous studies have shown that NMBs reduce oxygen consumption and energy expenditure. I think it is worth investigating whether short-term neuromuscular blockade could help speed cooling rates. In addition, since shivering is often triggered by a drop in temperature (rather than absolute temperature) neuromuscular blockers can prevent heat generation by shivering.
So… what’s the take home message of all of this? Well, it’s safe to say yourpt needs more than just some cowbell. How can you modify your practice to give your patient the best chance of survival?– here are my recommendations for management of heatstroke, based on the current best available evidence…
First, aggressively support your patient.
Rapidly cool the patient by: Conduction – with cooling blankets UNDER the patient; ice massage on OVER the patient; and cool IV fluids running IN the patient. Evaporation – with water dousing or cold water mist. And Convection – by fanning the patient, which will also speed evaporative cooling. I should point out that in order to do this, you should plan ahead by storing 1-2 liters of IV fluid in a medication refrigerator and know who to call in order to get your maintenance crews’ fan.
If you act early and aggressively, with a focus on cooling, you have the chance to…
Thank you for your attention. I’d be happy to take any questions?