Conference Notes 7-17-2012



Triage colors: green = walking wounded, red=emergent, yellow=care can be delayed for a few hours, black=dead.

JCAHO requires a hospital disaster plan to be activated 2 times per year.

A disaster is defined when an event overwhelms a facility’s ability to respond appropriately.

The most common important problem in a disaster is communication difficulties.

Mass gathering =1000 or more people at an event.  The most common injuryat a mass gathering is dermal injury.

Triage is a dynamic process that requires re-eval and re-assessment of patients.

The command station at a HAZMAT scene should be uphill and upwind from the hazardous materials.

Regarding decontamination; if there is ocular exposure address eye irrigation first.  Gross decontamination takes precedence over airway management.  Removing clothes is the first and usually most effective step of decontamination.

Class A bioterrorism agent:  Anthrax, plague, ebola, small pox, botulism, tularemia.     

Radiation:  Alpha particles can be blocked by paper or clothing.  It is unlikely to give whole body radiation unless ingested.   The earliest lab indicator of acute radiation syndrome is decreased lymphocyte count.  

Under NIMS, in a disaster situation, materials management is under the responsibility of the Logistics Section of the disaster response team.  Logistics is in charge of all the equipement and materials necessary for a disaster response.

START triage algorithms are based on a quick assessment of the patients respirations, perfusion and mental status.  


Acetaminophen (APAP):  Completely absorbed within 4 hours.   A 2 hour Tylenol level predicts a 4 hour level.   APAP is eliminated by glucuronidation and sulfation.  5-10% is metabolized by the cytochromes to NAPQI which is the toxic metabolite.   NAPQI attacks cells in the liver.  Glutathione detox’s normally .  But if glutathione gets depleted in a Tylenol overdose you get liver damage.   Extended relief acetaminophen tab has similar overdose characteristics as regular tab.  If your 4 hour level is non-toxic then your 6 and 8 hours levels will likely be non-toxic as well.  Still, check 6 and 8 hour levels.

APAP overdose is initially asymptomatic.  After 24 hours pt’s develop nausea and vomiting.   Time of ingestion is the earliest time, not the latest time of ingestion.  

No routine gastric lavage or activated charcoal for APAP overdoses.  

Toxic ingestion of APAP=150mg/l at 4 hours  to 4mg/l at 24 hours.

N-acetylcystine (NAC) is the antidote for Tylenol overdose.  Oral dosing is  140mg/kg initial dose  followed by 70mg/kg q 4 hours for 72 hours.   Now IV Nac is available with a 21 hour protocol.  You can probably stop NAC when serum Tylenol level is less than 10mg/l.   NAC can falsely elevate the INR slightly.   If patient has signs of liver damage, you give NAC until liver enzymes are less than 1000.  Ted recommends using IV acetadote over po NAC.   It is just easier.  

Liver transplant criteria: Elevated INR, elevated Cr, and encephalopathy.    To increase sensitivity to pick up all potential transplant patients is lactate >3.5 or abg <7.3 after initial resuscitation.    You will see these abnormalities in late presenting patients or patients in the ICU who are not doing well.   If a patient with acidosis or diminished liver function, transfer that patient to a transplant center.

Salicylate (ASA):  Oil of wintergreen has a massive amount of salicylate in it’s formulation.   ICY-HOT also has salicilyate in it’s formulation.   

Treat with IV fluids, Bicarb drip and repeated doses of activated charcoal.   You want to alkalinize the serum and urine to ion trap the ASA in the urine.   This mechanism also keeps hydrogen ions out of the cns and heart.   You need to supplement potassium as well.

ASA  uncouples oxidative phosphorylation.   Most common cause of death is cardiac dysfunction.   Pt’s will have tinnitus.   Pt’s will have tachypnea due to metabolic acidosis and primary respiratory alkalosis.

Chronic ASA is very problematic due to whole body burden of ASA.

Harwood Comment: Is there vomiting with oral potassium supplementation in these patients.  Ted replied he has not seen that problem.

Indications for dialysis: deterioration, aletered mental status, pulmonary edema, severe acidosis, renal failure, worsening coagulopathy, ASA concentrations of 80-100 mg/dl.

Ted made a comment that there are case reports of ASA toxicity developing in a patient with an initial neg level due to irregular absorption of ASA.




Red on yellow, Kill a fellow=Coral snake.   Red on black, venom lack=non-venomous king snake.  Coral snakes are common in the southern US.

Crotalids (Rattlesnakes and others) have elliptical eyes, triangular head, a heat sensing pit, and retractible fangs.

Snake venom: crotalids have proteolytic venoms and can cause systemic toxicity.  Elapid venoms are neuro toxins.

Crotalid bites cause local reactions.  Can have systemic symptoms as well including hematologic and gi symptoms, rhabdomyolysis.

Elapid bites (coral snakes): pt can be asymptomatic up to 12 hours then develop paralysis.

Poison control center # anywhere in US 1-800-222-1222.

Asymptomatic patients: crotalid bites observe for 8 hours.   Elapid bites give antivenin.

Field management: ok to irrigate and splint wound and avoid strenuous exertion, and take a picture if snake if easily available.  Don’t use tourniquets, suction, direct handling  of snake.

Management: Antivenom, tetanus prophylaxis, avoid blood products unless pt is hemorrhaging to death.  Antivenom should be used prior to fasciotomy for swollen limb.   Anti-venom is not a weight based dose.  Same dose for adults and kids.   Patients may have an anaphylactoid reaction from antivenom.   4-6 doses of Crofab antivenom given for spread of swelling, hematologic abnormalities, or unstable vital signs.  (spread-bled-almost dead)

Elapid (coral snakes) bites management: look for signs of weakness including respiratory parameters such as low maximal inspiratory pressure, capnography.  Everybody gets coral snake antivenin because pt’s can be assymptomatic initially.  Repeat dosing based on clinical status.  This antivenin can cause anaphylatoid reactions as well.

Non-venomous snakebites: get xray to check for fb. Give prophylactic antibiotics (gram positive coverage). 

Gila monster bite: wound care, antibiotic prophylaxis. No anti-venin.

Harwood comment: for the snake mnemonic start with red like a fang mark.  Red on yellow, kill a fellow. Red on black, venom lack.    


Jelly fish have nematocysts with venom that is painful and toxic to humans.  Nematocysts can be rinsed off with vinegar.

Cubozoa: Box Jellyfish is indigenous to northern Australia and SE asia. Clear color. Can cause local reaction and in worst case cardiovascular collapse. Rinse off with vinegar.  Don’t rinse with fresh water or urine.  Nematocysts need to be removed afterward with tweezers or razor.  Give antivenom 1-2 amps IV or 3 amps IM.  It is sheep derived.  Can cause anaphylaxis or serum sickness.

Irukandji Jelly fish:  Irukandji syndrome=30 minutes after stung, low back pain, muscle cramps, hair stands up, anxiety, sweating, tachy, vomit, oliguria, cerebral edema, pulmonary edema.   Lasts 5 days to 2 weeks.

Portuguese man of war: Larger than box jelly fish, Blue color. Has blue sail above water. Tentacles may be 100 feet long. Complex venom that is hemolytic and cytolytic.  Intense local pain, hemolysis, cardiac conduction abnormality, recurrent urticaria.   TX: neutralize with salt water.  Don’t use vinegar because it causes 30% nematocyst discharge.

Seabathers eruption: Due to larvae of jelly fish.  Contact dermatitis.  Pruritic papules.  Lasts for 2 weeks.  TX with steroids and antihistamines.

Stingray: Has a serrated spine with venom. If you step on them they can sting you.  Steve Irwin was killed by one.  Local reaction, tremors, convulsions, CV collapse.  Tx with tetanus shot, hot water deactives venom (soak extremity), irrigate wound, systemic analgesia, cover gram negs with abx.

Lionfish:  Envenomation causes pain, swelling, blistering, weaknss.  Treat with hot water and wound care, and tetanus shot.

Stonefish: Highly toxic.  Immediate and intense pain, delirium and cardiovascular collapse.   Treat with hot water, support vitals, wound care, and tetanus shot, antibiotics.

Sea Urchins: pain and pruritus.  Relatively benign envenomations.  Treat with hot water.  Get xray to check for retained spine.  Treat pain.


Laceration repair is the most common missing piece of documentation.

For all procedures use the procedure macros in Picis.