Environmental Environmental exposuresexposures
Nikki Waller, MDNikki Waller, MDMedical Student ClerkshipMedical Student Clerkship
2009-20102009-2010
Self-Directed Learning AssessmentsSelf-Directed Learning Assessments
SnakesSnakes
8,000 venomous snake bites/yr in US8,000 venomous snake bites/yr in US ~10 deaths/yr~10 deaths/yr 25% bites are dry bites25% bites are dry bites Venomous:Venomous:
1.1. Imported snakesImported snakes2.2. Coral SnakesCoral Snakes3.3. Crotaline Snakes/Pit VipersCrotaline Snakes/Pit Vipers
RattlesnakesRattlesnakesCopperheadCopperheadWater MoccasinWater MoccasinMassasaugaMassasauga
www.zanesville.ohiou.edu
Coral SnakeCoral Snake
Brightly ColoredBrightly Colored Black-Red-Yellow Black-Red-Yellow
patternpattern RED touches YELLOW RED touches YELLOW
= kill a fellow = kill a fellow vs vs
Red on Black = Red on Black = venom lackvenom lack
ONLY Eastern Coral ONLY Eastern Coral Snake bite requires Snake bite requires treatment treatment
www.zanesville.ohiou.edu
Coral SnakeCoral Snake
Eastern Coral Snake venom is potent Eastern Coral Snake venom is potent neurotoxinneurotoxin
Symptoms:Symptoms:• TremorTremor• SalivationSalivation• Respiratory paralysisRespiratory paralysis• SeizuresSeizures• Bulbar palsies( dysarthria, diplopia, Bulbar palsies( dysarthria, diplopia,
dysphsgia)dysphsgia)
Coral SnakeCoral Snake
Admit for 24-48 hours observationAdmit for 24-48 hours observation ALL patients with POTENTIAL ALL patients with POTENTIAL
envenomation – 3 vials of antivenimenvenomation – 3 vials of antivenim Antivenim (Antivenim (M fulviusM fulvius))
• At least 3 vialsAt least 3 vials• If sxs – additional dosesIf sxs – additional doses
Symptomatic Pts are admitted to ICUSymptomatic Pts are admitted to ICU
Arizona Coral Snake Arizona Coral Snake
Sonoran(Arizona) Sonoran(Arizona) Coral Snake bite Coral Snake bite does not require does not require treatmenttreatment
Few symptomsFew symptoms
Local wound care Local wound care only only
www.pitt.edu
Coral Snake MimicCoral Snake Mimic
Red and yellow, kill Red and yellow, kill a fellow; red and a fellow; red and black, friend of black, friend of Jack." Jack."
www.stetson.edu
jungledomain.org
Crotalinae (Pit Vipers) BitesCrotalinae (Pit Vipers) Bites Identified byIdentified by
• 2 retractable fangs2 retractable fangs• Heat sensitive Heat sensitive
depressions (pits) depressions (pits) located between each located between each eye & nostril eye & nostril
Clinical Effects depend on:Clinical Effects depend on:• Size & species of snakeSize & species of snake• Age & size of victimAge & size of victim• Time since biteTime since bite• Characteristics of bite Characteristics of bite
Crotalinae (Pit Vipers) BitesCrotalinae (Pit Vipers) Bites Hallmark of bite – fang marks Hallmark of bite – fang marks
with local pain & swellingwith local pain & swelling Severity classification:Severity classification:
• Degree of local injuryDegree of local injury Swelling, pain, ecchymosis Swelling, pain, ecchymosis
• Degree of systemic Degree of systemic toxicity toxicity
Hypotension, Hypotension, tacchycardia, paresthesiastacchycardia, paresthesias
• Evolving coagulopathyEvolving coagulopathy Thrombocytopenia, Thrombocytopenia,
elevated PT, elevated PT, hypofibrinogenemiahypofibrinogenemia
Crotalinae (Pit Vipers) BitesCrotalinae (Pit Vipers) Bites Any 1 of the 3 classes = envenomationAny 1 of the 3 classes = envenomation No sxs at 8-12 hours = no bite or dry biteNo sxs at 8-12 hours = no bite or dry bite All envenomations have swelling at 30 minutes All envenomations have swelling at 30 minutes
• Rarely onset up to 12 hoursRarely onset up to 12 hours Degree of envenomationDegree of envenomation
• Minimal: local sxs onlyMinimal: local sxs only• Moderate: systemic sxs and coagulation parameter Moderate: systemic sxs and coagulation parameter
abnormalitiesabnormalities• Severe: extensive swelling, potentially life threatening Severe: extensive swelling, potentially life threatening
systemic signs, markedly abnormal coagulation systemic signs, markedly abnormal coagulation parameters that may result in bleedingparameters that may result in bleeding
Crotalinae (Pit Vipers) BitesCrotalinae (Pit Vipers) Bites
Diagnostic tests: CBC, Coags, Type & Diagnostic tests: CBC, Coags, Type & Screen Screen
Treatment:Treatment: • Resources: Arizona Poison Control 520-Resources: Arizona Poison Control 520-
626-6016626-6016• Prehospital:Prehospital:
Minimize physical activity & remain calmMinimize physical activity & remain calm Immobilize bite site & place in neutral Immobilize bite site & place in neutral
position below heart position below heart
Crotalinae (Pit Vipers) BitesCrotalinae (Pit Vipers) Bites
Treatment (continued):Treatment (continued): Cardiac monitor, IV’s, resuscitate based on Cardiac monitor, IV’s, resuscitate based on
ACLSACLS Local wound careLocal wound care
• Remove FBRemove FB• Td BoosterTd Booster
Measure & Record limb circumference at Measure & Record limb circumference at several sites above and below site of bite, several sites above and below site of bite, repeat q 30 minutesrepeat q 30 minutes
Mark border of advancing edema q 30minMark border of advancing edema q 30min
CroFabCroFab Polyvalent Crotalidae Immune Fab(CROFAB)Polyvalent Crotalidae Immune Fab(CROFAB)
• Any pt with progressive swelling, systemic sxs or Any pt with progressive swelling, systemic sxs or coagulopathy coagulopathy
• Sheep derived antivenimSheep derived antivenim• Replaced Antivenin (Crotalidae) Polyvalent( equine Replaced Antivenin (Crotalidae) Polyvalent( equine
derived)derived)• Initial Dose: 4-6 vials IVInitial Dose: 4-6 vials IV• Diluted in 250ml H20 & infused over 60 minsDiluted in 250ml H20 & infused over 60 mins• Dosing same for children, amount of diluent is adjustedDosing same for children, amount of diluent is adjusted• @1HR, if any of 3 parameters have not halted, repeat @1HR, if any of 3 parameters have not halted, repeat
dose of 4-6 vials givendose of 4-6 vials given• Labs checked q4 h or after each round of CrofabLabs checked q4 h or after each round of Crofab• End point is arrest of sxs and coagulopathy, IF NOT KEEP End point is arrest of sxs and coagulopathy, IF NOT KEEP
TREATINGTREATING• After control of sxs, Protocol After control of sxs, Protocol
CroFabCroFab
• @1HR, if any of 3 parameters have not @1HR, if any of 3 parameters have not halted, repeat dose of 4-6 vials givenhalted, repeat dose of 4-6 vials given
• Labs checked q4 h or after each round Labs checked q4 h or after each round of Crofabof Crofab
• End point is arrest of sxs & End point is arrest of sxs & coagulopathy, IF NOT KEEP TREATINGcoagulopathy, IF NOT KEEP TREATING
• After control of sxs, Protocol as follows:After control of sxs, Protocol as follows: 2 vials q 6h for additional 18 hours ( 3 more 2 vials q 6h for additional 18 hours ( 3 more
doses)doses)
CroFabCroFab The cost of CroFab is $ 750 The cost of CroFab is $ 750
per vialper vial Total Total costcost of therapy for a of therapy for a
snakebite ranges from snakebite ranges from $10500 (4-4-2-2-2 vials) to $10500 (4-4-2-2-2 vials) to $13500 (6-6-2-2-2 vials) $13500 (6-6-2-2-2 vials)
Average treatment Cost: Average treatment Cost: $10,000 per patient$10,000 per patient
Estimated 8,000 venomous Estimated 8,000 venomous snakebites in the US each snakebites in the US each yearyear
Market potential of up to Market potential of up to US$80 million/yrUS$80 million/yr
protherics.matinee.co.uk/ products/Critical_Care_Products.asp
Compartment SyndromeCompartment Syndrome
Pressure > 30 : limb elevation & Pressure > 30 : limb elevation & repeat CroFab dosingrepeat CroFab dosing
Persistently elevated PressurePersistently elevated Pressure• Mannitol 1-2 g/Kg IV over 30 minutesMannitol 1-2 g/Kg IV over 30 minutes• Surgical Consult for FasciotomySurgical Consult for Fasciotomy
Crotalinae (Pit Vipers) BitesCrotalinae (Pit Vipers) Bites
DISPOSITIONDISPOSITION• Observe for at least 8 hoursObserve for at least 8 hours• Severe bites and anyone receiving Severe bites and anyone receiving
continued antivenin -> ICU continued antivenin -> ICU • Must warn patients about Serum Must warn patients about Serum
Sickness with CrofabSickness with Crofab 16% patients16% patients 7-14 days after therapy7-14 days after therapy Tx with Prednisone 60mg/d PO tapered over Tx with Prednisone 60mg/d PO tapered over
1-2 weeks 1-2 weeks
Pit Vipers in the US Pit Vipers in the US
Western Diamondback Western Diamondback Rattlesnake Habitat Rattlesnake Habitat
Eastern Diamondback Eastern Diamondback Rattlesnake Habitat Rattlesnake Habitat
Gila Monster Bite Gila Monster Bite Tenacious biteTenacious bite Often lizard still attachedOften lizard still attached To remove: To remove:
• Place lizard on solid Place lizard on solid surfacesurface
• Submersion in waterSubmersion in water• Cast SpreaderCast Spreader• Local irritating flameLocal irritating flame
Local wound careLocal wound care Search for teethSearch for teeth No further treatment No further treatment
required required
www.californiaherps.com
www.mendosa.com
Gila Monster BiteGila Monster Bite
Symptoms: Pain & Symptoms: Pain & swellingswelling
Rare systemic Rare systemic toxicitytoxicity
Systemic SXS:Systemic SXS:• DiaphoresisDiaphoresis• ParesthesiaParesthesia• WeaknessWeakness• HTNHTN
www.aintitcool.com
Hypothermia: Epidemiology Hypothermia: Epidemiology Defined as a core temperature < 35°C (95°F)Defined as a core temperature < 35°C (95°F) US Deaths:700 per yr US Deaths:700 per yr
• Half > 65 yoHalf > 65 yo At Risk: Age Extremes & Altered sensoriumAt Risk: Age Extremes & Altered sensorium ““Causes of Hypothermia: Clinical SettingsCauses of Hypothermia: Clinical Settings
• ““Accidental” (environmental)Accidental” (environmental)• MetabolicMetabolic• Hypothalamic and CNS dysfunctionHypothalamic and CNS dysfunction• Drug-inducedDrug-induced• SepsisSepsis• Dermal diseaseDermal disease• Acute incapacitating illnessAcute incapacitating illness• Iatrogenic (fluid resuscitation)Iatrogenic (fluid resuscitation)
HypothermiaHypothermia ETIOLOGIES:ETIOLOGIES: Metabolic causes Metabolic causes
• Hypothyroidism, hypoadrenalism, hypopituitarismHypothyroidism, hypoadrenalism, hypopituitarism• Each lead to a decrease in metabolic rateEach lead to a decrease in metabolic rate• Hypoglycemia also may lead to hypothermia Hypoglycemia also may lead to hypothermia
CNS dysfunction CNS dysfunction
• Head trauma, tumor, strokeHead trauma, tumor, stroke• Wernicke diseaseWernicke disease
Potentially reversible with thiamine Potentially reversible with thiamine
Alcohol & DrugsAlcohol & Drugs• In the US, most hypothermic patients are intoxicated In the US, most hypothermic patients are intoxicated • Ethanol Ethanol
Vasodilator & anesthetic and CNS depressant effectsVasodilator & anesthetic and CNS depressant effects Don’t Feel the Cold and Don’t respond to it Don’t Feel the Cold and Don’t respond to it
HypothermiaHypothermia ETIOLOGIES:ETIOLOGIES: SepsisSepsis
• Poor prognostic factor in patients with bacteremiaPoor prognostic factor in patients with bacteremia
Severe infections, DKA, immobilizing injuries, and Severe infections, DKA, immobilizing injuries, and
various other conditions impair thermoregulatory various other conditions impair thermoregulatory functionfunction
Trauma patientsTrauma patients• Resuscitation with room-temperature fluid & cold bloodResuscitation with room-temperature fluid & cold blood• At risk: Pts undergoing massive volume replacementAt risk: Pts undergoing massive volume replacement
Hypothermia: Physiology Hypothermia: Physiology 32° to 35°C (89.6°–95°F) = “mild” hypothermia32° to 35°C (89.6°–95°F) = “mild” hypothermia Excitation (responsive) stage Excitation (responsive) stage Body attempts to retain & generate heatBody attempts to retain & generate heat HR, CO & BP all riseHR, CO & BP all rise
Below 32°C (89.6°F) = moderate hypothermiaBelow 32°C (89.6°F) = moderate hypothermia Slowing (adynamic) stageSlowing (adynamic) stage Progressive slowdown of bodily functions & Progressive slowdown of bodily functions &
metabolism metabolism Decrease O2 utilization & CO2 productionDecrease O2 utilization & CO2 production Below 30° to 32°C (86°–89.6°F) - shivering stops Below 30° to 32°C (86°–89.6°F) - shivering stops
Hypothermia: CardiacHypothermia: Cardiac Dysrhythmias at Temp < 30°C (86°F)Dysrhythmias at Temp < 30°C (86°F)
Typical sequence:Typical sequence: Sinus Brady -> slow AFIB -> VFIB -> asystoleSinus Brady -> slow AFIB -> VFIB -> asystole
Myocardium - extremely irritableMyocardium - extremely irritable• VFIB induced by rough handling of patientVFIB induced by rough handling of patient
Dysrhythmias:Dysrhythmias: Sinus bradycardia Sinus bradycardia AFIB or flutter AFIB or flutter Nodal rhythms Nodal rhythms AV block AV block PVCs PVCs Ventricular fibrillation Ventricular fibrillation Asystole Asystole
HypothermiaHypothermia
ECG Changes in Hypothermia:ECG Changes in Hypothermia:T-wave inversionsT-wave inversionsPR, QRS, QT prolongationPR, QRS, QT prolongationMuscle tremor artifactMuscle tremor artifactOsborn (J) waveOsborn (J) wave
Osborn (J) wave:Osborn (J) wave: • Slow, positive deflection at the end of Slow, positive deflection at the end of
the QRS complexthe QRS complex• Characteristic, not pathognomonicCharacteristic, not pathognomonic
HypothermiaHypothermia
Pulmonary:Pulmonary:• Initial tachypnea -> decrease RR & TVInitial tachypnea -> decrease RR & TV• Aspiration pneumonia risk - Bronchorrhea & depressed Aspiration pneumonia risk - Bronchorrhea & depressed
gag reflexgag reflex• ABG: false high PO2 and PCO2 & lower pH ABG: false high PO2 and PCO2 & lower pH • Leftward shift of OxyHgb dissociation curve Leftward shift of OxyHgb dissociation curve
thus impairing O2 releasethus impairing O2 release
CNS:CNS:
• Depression of consciousness Depression of consciousness • SXS: Mild incoordination then confusion, lethargy & SXS: Mild incoordination then confusion, lethargy &
comacoma• Pupils may be dilated & non reactivePupils may be dilated & non reactive
HypothermiaHypothermia
RenalRenal • Cold diuresis c resultant volume lossesCold diuresis c resultant volume losses• Prone to rhabdomyolysis Prone to rhabdomyolysis • Prone to ARF from myoglobinuria & Prone to ARF from myoglobinuria &
hypoperfusionhypoperfusion
HematologyHematology• Prone to intravascular thrombosis and Prone to intravascular thrombosis and
subsequent embolic complicationssubsequent embolic complications• Prone to DIC Prone to DIC • Prone to bleedingProne to bleeding
Hypothermia: DiagnosisHypothermia: Diagnosis
Rectal Temp Rectal Temp Some standard clinical thermometers Some standard clinical thermometers
record only to 34.4°C (94°F)record only to 34.4°C (94°F) Electronic thermometers with flexible Electronic thermometers with flexible
probes can continuously monitor probes can continuously monitor rectal, bladder or esophageal Temprectal, bladder or esophageal Temp
Hypothermia:Treatment Hypothermia:Treatment
ABCsABCs Cardiac Monitor, pulse OxCardiac Monitor, pulse Ox Continuous or repeated Temperature Continuous or repeated Temperature
recordingsrecordings Drugs:Drugs:
• IV thiamine 50 mgIV thiamine 50 mg• If FSBS low: 50 to 100 mL of D50If FSBS low: 50 to 100 mL of D50
Hypothermia:TreatmentHypothermia:Treatment
Rewarming: Active & PassiveRewarming: Active & Passive• Stable cardiac rhythm & Vitals: Stable cardiac rhythm & Vitals:
Passive rewarmingPassive rewarming Noninvasive Active rewarming:Noninvasive Active rewarming:
• Forced-air rewarming, warm O2 & warm IVFForced-air rewarming, warm O2 & warm IVF
• Less than 30° (86°F) Less than 30° (86°F) Rapid rewarming until the temp is 30° to Rapid rewarming until the temp is 30° to
32°C (86°–89.6°F) 32°C (86°–89.6°F) • Minimize dysrhythmiasMinimize dysrhythmias
Hypothermia:TreatmentHypothermia:Treatment
Passive rewarming:Passive rewarming: 1. Removal from cold environment 1. Removal from cold environment 2. Insulation 2. Insulation
Active external rewarming:Active external rewarming: Warm water immersion Warm water immersion Heating blankets set at 40°C Heating blankets set at 40°C Radiant heat Radiant heat Forced air ( BEAR Hugger) Forced air ( BEAR Hugger)
Hypothermia:TreatmentHypothermia:Treatment Active core rewarming at 40°C:Active core rewarming at 40°C:
• Inhalation rewarming Inhalation rewarming • Warmed, humidified air by face mask or ETTWarmed, humidified air by face mask or ETT
• Heated IV fluidsHeated IV fluids• Warmed to 40°C (104°F)Warmed to 40°C (104°F)
• GI tract lavageGI tract lavage• Pulmonary aspiration if unprotected airwayPulmonary aspiration if unprotected airway
• Bladder lavageBladder lavage• Peritoneal lavagePeritoneal lavage
• Potassium-free dialysis solution at 104°–113°FPotassium-free dialysis solution at 104°–113°F• 2 catheters (instillation & removal)2 catheters (instillation & removal)
Hypothermia:TreatmentHypothermia:Treatment
Active core rewarming at 40°C:Active core rewarming at 40°C:• Pleural lavagePleural lavage
L thoracic cavity - heated fluid in proximity to the L thoracic cavity - heated fluid in proximity to the heart heart
2 tubes – Instillation and removal2 tubes – Instillation and removal
• Extracorporeal rewarmingExtracorporeal rewarming Pump-assisted cardiopulmonary bypass via femoral Pump-assisted cardiopulmonary bypass via femoral
vessels is the most common vessels is the most common Right atrial–aortic bypass using a median sternotomy Right atrial–aortic bypass using a median sternotomy
and heated hemodialysisand heated hemodialysis
• Mediastinal lavage via thoracotomy Mediastinal lavage via thoracotomy
Local Cold Induced Injury Local Cold Induced Injury
FrostnipFrostnip: less severe than frostbite, no : less severe than frostbite, no tissue loss, resolves with rewarmingtissue loss, resolves with rewarming
Trench footTrench foot: cooling of tissue in a wet : cooling of tissue in a wet environment at above freezing temp over environment at above freezing temp over hrs to dayshrs to days
Chilblains(pernio)Chilblains(pernio): painful & inflamed : painful & inflamed lesions from chronic & intermittent lesions from chronic & intermittent exposure to damp non-freezing ambient exposure to damp non-freezing ambient temp temp
Local Cold Induced InjuryLocal Cold Induced Injury First Degree FrostbiteFirst Degree Frostbite: superficial injury; : superficial injury;
edema, burning & erythema edema, burning & erythema Second Degree FrostbiteSecond Degree Frostbite: above + : above +
blisteringblistering Third Degree FrostbiteThird Degree Frostbite: involves full : involves full
thickness skin & subdermal tissuethickness skin & subdermal tissue Fourth Degree FrostbiteFourth Degree Frostbite: involves above + : involves above +
subcutaneous tissue, muscle, tendon & subcutaneous tissue, muscle, tendon & bone bone • Cyanotic & insensate tissue, hemorrhagic Cyanotic & insensate tissue, hemorrhagic
blisters & skin necrosis blisters & skin necrosis • Later becomes mummified Later becomes mummified
Local Cold Induced InjuryLocal Cold Induced Injury
Treatment:Treatment:• Chilblains & Trench footChilblains & Trench foot: elevate, warm, : elevate, warm,
bandagebandage Rx: Nifedipine 20mg PO TID, Topical steroids, Rx: Nifedipine 20mg PO TID, Topical steroids,
prednisone, prostaglandin E1prednisone, prostaglandin E1
• FrostbiteFrostbite: rapid rewarm with water at 42: rapid rewarm with water at 42oo C C (107(107oo F) for 10-30 minutes F) for 10-30 minutes
Rx: Narcs, ibuprofen, aloe vera, PCN G 500,000 u Rx: Narcs, ibuprofen, aloe vera, PCN G 500,000 u PO q6 for 2-3 daysPO q6 for 2-3 days Debride clear blisterDebride clear blister Don’t puncture Hemorrhagic blistersDon’t puncture Hemorrhagic blisters NO DRY AIR REWARMINGNO DRY AIR REWARMING
Heat Emergencies Heat Emergencies
Heat Exhaustion:Heat Exhaustion:• Sxs: malaise, fatigue, weakness, dizziness, Sxs: malaise, fatigue, weakness, dizziness,
syncope, HA, nausea, vomiting, myalgias, syncope, HA, nausea, vomiting, myalgias, diaphoresis, tachypnea, tachycardia, diaphoresis, tachypnea, tachycardia, orthostatic hypotensionorthostatic hypotension
• Temp: elevated to normalTemp: elevated to normal• Sensorium and Neuro Exam: NORMAL Sensorium and Neuro Exam: NORMAL • Dx Work-up: Check CK to r/o RhabdoDx Work-up: Check CK to r/o Rhabdo• TX: rest, evaporative cooling, IV fluidsTX: rest, evaporative cooling, IV fluids• Dispo: D/C except Electrolyte abnormalities or Dispo: D/C except Electrolyte abnormalities or
Co-morbiditiesCo-morbidities
Heat EmergenciesHeat Emergencies Heat SyncopeHeat Syncope: :
• Cause: volume depletion, peripheral vasodilation, Cause: volume depletion, peripheral vasodilation, decreased vasomotor tonedecreased vasomotor tone
• R/O other causes of syncopeR/O other causes of syncope Heat CrampsHeat Cramps: :
• Painful muscle spasms of calves, thighs, shouldersPainful muscle spasms of calves, thighs, shoulders• Cause: dilutional hyponatremia from replacement with Cause: dilutional hyponatremia from replacement with
free waterfree water Heat tetanyHeat tetany::
• Paresthesias of extremities & circumoral areaParesthesias of extremities & circumoral area• Carpopedal spasms Carpopedal spasms • Cause: respiratory alkalosis from hyperventilation Cause: respiratory alkalosis from hyperventilation
Heat Emergencies: Heat StrokeHeat Emergencies: Heat Stroke Difference from Heat exhaustion is Altered Mental Difference from Heat exhaustion is Altered Mental
Status & Definite elevated Temp Status & Definite elevated Temp Core Temp 40 - 47Core Temp 40 - 47oo C C Neurologic SxsNeurologic Sxs: ataxia, confusion, bizarre : ataxia, confusion, bizarre
behavior, agitation, Szs, obtundation & Coma behavior, agitation, Szs, obtundation & Coma Risk FactorsRisk Factors: Age <4 or > 75yo; CHF, psych : Age <4 or > 75yo; CHF, psych
illnesses, ETOH, dehydration, poverty, social illnesses, ETOH, dehydration, poverty, social isolation, poor conditioning, no access to air isolation, poor conditioning, no access to air conditioning, poorly acclimated to warm weather, conditioning, poorly acclimated to warm weather, medications (B-Blockers, Ca Channel Blockers, medications (B-Blockers, Ca Channel Blockers, Anti-cholinergics) Anti-cholinergics)
Heat Emergencies: Heat StrokeHeat Emergencies: Heat Stroke
Diagnostic Work-upDiagnostic Work-up: CBC, Electrolytes, CK, : CBC, Electrolytes, CK, LFTs, ETOH level, Tox Screen, Coags, UA, LFTs, ETOH level, Tox Screen, Coags, UA, urine myoglobin, U preg, ABG, CXR, EKGurine myoglobin, U preg, ABG, CXR, EKG
Differential DiagnosisDifferential Diagnosis: sepsis, meningitis, : sepsis, meningitis, encephalitis, toxidromes (anticholinergic, encephalitis, toxidromes (anticholinergic, PCP, salicylates, sympathomimetics), DKA, PCP, salicylates, sympathomimetics), DKA, thyrotoxicosis, status epilepticus, stroke, thyrotoxicosis, status epilepticus, stroke, neuroleptic malignant syndrome, neuroleptic malignant syndrome, malignant hyperthermia malignant hyperthermia
Heat Emergencies: Heat StrokeHeat Emergencies: Heat Stroke
Treatment:Treatment: ABCsABCs ETT if altered mental status, hypoxia or ETT if altered mental status, hypoxia or
diminished gag reflexdiminished gag reflex Volume Replacement: dehydrated & Volume Replacement: dehydrated &
prevent Rhabdomyolysisprevent Rhabdomyolysis Evaporative Cooling: disrobe pt; spray Evaporative Cooling: disrobe pt; spray tepidtepid
water at patient via surrounding fans water at patient via surrounding fans Treat shivering with BenzodiazepinesTreat shivering with Benzodiazepines
Heat Emergencies: Heat StrokeHeat Emergencies: Heat Stroke
Aggressive CoolingAggressive Cooling: immersion cooling, : immersion cooling, cold water gastric & urinary bladder cold water gastric & urinary bladder lavage, thoracostomy lavage, lavage, thoracostomy lavage, cariopulmonary bypasscariopulmonary bypass
SeizuresSeizures: treat with Benzos: treat with Benzos RhabdomyolysisRhabdomyolysis::
• IV hydration, furosemide 40mg IV, Na BicarbIV hydration, furosemide 40mg IV, Na Bicarb HyperkalemiaHyperkalemia: normal protocol: normal protocol Admission: ICUAdmission: ICU