Urumov Study Guide Environmental
Harwood comment: If a patient is shivering, they will survive hypothermia. You just need to passively rewarm them. If they are hypothermic and not shivering, you need to initiate active rewarming.
Treat heat cramps by removing the patient from the hot environment andgiving IV saline or oral fluids with electrolyte replacement.
Prickly heat is due to plugging of glands.
*1 Prickly Heat
Heat Stroke defined by elevated core temperature with mental status changes due to environmental and exertional heat. It should be treated by either evaporative cooling or immersion in an ice bath.
Prognosis for heat stroke is best determined by duration of hyperthermia and the patient’s comorbidities.
We had a discussion about the definition of drowning: The ILCOR recommends that the terms dry and wet drowning, active and passive drowning, near drowning, and secondary drowning no longer be used as they are confusing and not clinically relevant.
In accordance with the ILCOR guidelines, patients should be referred to as drowning victims if they have suffered a suspected respiratory injury following submersion in a liquid medium, regardless of their clinical status, which may vary from essentially asymptomatic to severely ill at time of presentation. Additional descriptors such as whether there was a precipitating event that led to drowning or whether the drowning was witnessed may be used as necessary. The primary outcome of a drowning episode is either death or survival. Adopting this clinical nomenclature will allow future studies to better characterize, study, and risk stratify drowning victims. (Trauma Reports)
*2High Altitude Illness
Indications for antivenin: Progression of swelling. Low platelets/low fibrinogen. Hand bites. Unstable vitals/shock. Rhabdomyolysis.
48 hour absolute lymphocyte count is the best predictor of outcome after radiation exposure. If the absolute lymphocyte count is <300 the prognosis is dismal.
*3Gamma rays are the most penetrating radiation and can pass through all layers of the body. Alpha rays can be blocked by paper. Beta rays can be blocked by aluminum.
Treatment of jelly fish stings/burningincludes using vinegar as the first choice of irrigation solution. Ocean water is the second choice of irrigation solution. After irrigation use a razor or credit card edge to mechanically remove the nematocysts.
Scorpion stings cause: nystagmus, tongue fasiculations, swallowing difficulty, tachycardia/hypertension, in addition to burning pain and paresthesias at the site of sting. Treatment is pain management, wound care, tetanus prophylaxis, benzo’s, and supportive care.
Cirone/Tekwani Oral Boards
Case 1. Neonatal chlamydia pneumonia and conjunctivitis. Treat with oral erythromycin. Diagnosis is with conjunctival/nasopharyngeal culture. You need to swab the epithelial cells in the conjunctiva. Even in a well-appearing child, treat with oral antibiotics.
*7 Neonatal chlamydial conjunctivitis
Case 2. Torison of appendix testes. Rule out torsion and reassure patient’s parent about the benign nature of the disease.
Case 3. 5yo child with history of sickle cell disease. Patient has cough and fever. CXR shows a large right side infiltrate. Diagnosis is acute chest syndrome. Treatment is: IV Fluids, IV antibiotics, exchange transfusion. This patient also required intubation for respiratory failure.
Elise comment: In sickle cell patients, if you are considering exchange transfusion, it will depend on the HGB level. If the HGB level is very low, the patient just needs regular PRBC transfusion. If the HGB level is not particularly low then you do need to do an exchange transfusion.
Faculty consensus and AAP statement: For neonatal conjunctivitis and or pneumonia, you need oral erythromycin or azithromycin for 14 days.
Girzadas Study Guide Neurology
Faculty and Pharmacist discussion highlighting a recent change in acute ischemic stroke management: There are no longer any additional age, comorbidity restrictions for administering TPA in the 3-4.5 hours time window other than the usual contraindications to TPA for the 0-3 hour window.
We discussed the work up of vertigo at length. There was faculty consensus that it was difficult to do the HINTs testing in dizzy patients. HINTs has been shown to be highly accurate when compared to ABCD2 score and MRI for identifying central causes of vertigo, but all faculty said they were not using this physical exam method due to difficulty.
*10 HINTs vs ABCD2 score
*11 Some suggested Red Flags in the setting of Dizziness/Vertigo to consider Brain Imaging. These are red flags from my reading on this topic. This is not a validated list. It should be noted that CT scan is much less sensitive than MRI for posterior circulation strokes. Harwood commented that if he is going to image a patient with dizziness or vertigo he goes right to MRI.
Bamman/Ryan Oral Boards
Case 1. Rocky Mountain Spotted Fever. Adult male presented with rash and fever.
*4RMSF rash
Treatment is doxycycline 100mg q 12hours
Case 2. 24 yo male presents after being “Tased.” Vital are normal. Patient still has a Taser prong in his back. Taser prong was removed by making an incision in the skin to allow the barb to be removed. TDAP was updated. Wound was irrigated. Antibiotic ointment and bandage applied.
Dennis made the point that most taser prongs can be removed with simple traction on the prong.
Otherwise asymptomatic patients don’t need any cardiac work up . There was faculty consensus that if you have a young, healthy, asymptomatic patient who was “tased” and now is fine, you don’t need to do an EKG or labs.
Harwood comment: You could use a needle to cover the barb of the taser prong and remove the prong similar to the fish hook removal method.
*8 Needle over barb technique
Girzadas comment: If the taser prong resists minimal to moderate traction to remove, I think local anesthetic and making an incision to aid removal makes sense.
Case 3. 24yo female presents with depression, somnolent, and tearful. Patient is tachycardic and hypotensive. History reveals that patient is taking amitriptyline.
*5EKG c/w TCA overdose, note tachycardia, wide QRS complex and tall wide terminal R wave in AVR.
Treatment includes: IV Bicarb bolus and drip. IV fluids. You can use norepinepherine if the patient is hypotensive and unresponsive to IV fluids.
Pharmacist asked when would we use intralipids for TCA overdose. Faculty consensus wasthat they would use intralipids if no improvement with bicarbonate (still with wide complex QRS and still tachycardic).
Schmitz 5 Slide F/U
Pediatric patient presented with unilateral facial weakness, nystagmus and limited eye movements.
Diagnosis was Acute Disseminated Encephalomyelitis (ADEM). Typically presents with fever, headache, nausea and vomiting. Patients can have ataxia, cranial nerve palsies, altered mental status and seizures. Treatment is steroids and IVIG.
*7 ADEM
*8 Treatment for ADEM
Denk 5 Slide F/U
Adult male presents with loss of memory. No focal neuro findings on physical exam. CT head was normal. Labs were all normal.
*6Transient Global Amnesia
Cause is unknown. Leading theory is cerebral venous congestion. Heavy lifting or valsalva prior to episode can increase venous congestion in the cerebral veins. It is thought that possibly patients prone to TGA have incompetent head and neck venous valves.
Long term there may be possible mild cognitive impairment. No increased risk of stroke. Harwood comment: There is an association long term with dementia.