TOXICOLOGY

ENVIRONMENTAL

Warning: Lots of Material

Two 15 yo boys are brought in to the ED by police after reports of bizarre behavior outside a local convenience store. Both are intermittently laughing uncontrollably and seem to be responding to internal stimuli. Initial exam is remarkable for T 38.3 C, HR 116, flushed skin and dilated pupils. Police tell you that other teens at the store told them that the two drank a tea made from a common wild plant. They described the plant as a green roadside bush with large white flowers.

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Anti-Ach

• Mad as a hatter (delirium), Hot as a hare (hyperthermia), Blind as a bat (mydriasis, inability to accommodate), Dry as a bone (urinary retention, constipation, dry mucous membranes), Red as a beet (flushed), Tacky as a leisure suit (tachycardia)
• Seizures can also happen but NOT caused by the anti-Ach effect, caused by the co-ingestant properties…ie TCA
• Examples: TCA, Atropine, scopolamine, anti-histamine, jimsonweed, nightshade
• Tx: Benzos
• +/- Physostigmine (Acetylcholinesterase anatagonist)
• SE: seizures
• Contraindications: known TCA overdose, wide QRS, reactive airway disease, seizure hx

A 19-year-old woman presents to the ED after ingesting a bottle of pills in her medicine cabinet 3 hours prior to arrival. Vital signs are BP 115/65, HR 101, T 37.8°C, RR 29, and pulse ox 100% on room air. On exam, you note mild diffuse abdominal tenderness and she is complaining of a high pitched ringing noise in her ears. Laboratory results reveal WBC 10 000, Hgb 14, platelets 275 000, AST 70, ALT 85, alkaline phosphatase 75, sodium 143, potassium 3.7, chloride 98, bicarbonate 8, BUN 22, creatinine 0.9, and glucose 85. An ABG reveals pH 7.51, PaCO₂ 11, and PaO₂ 99. What did the patient most likely ingest?

Salicylates

• CP: Tinnitus, vertigo, tachypnea, N/V, abdominal pain, AMS, dysrhtymias, non-cardiogenic pulmonary edema, acute renal failure, hyperthermia, tachycardia , diaphoresis, GI hemorrhage (late complication)
• Chronic Overdose: elderly with unexplained CNS dysfunction with mixed AB disturbance with nml pH.

Tx: Urine alkalinization with HCO3 to maintain urine pH 7-8, serum pH 7.45-7.5. Hemodialysis.

• Intubation prn - MUST MATCH RR!

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Examples: ASA, Methyl salicyclate (oil of wintergreen), Pepto

PRN KCl replacement (low K prevents urinary alkalinzation due to H/K exchange in renal tubules)

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HD Indications: Acute level >100, Chronic level >50-60, seizure, coma, renal or hepatic failure, pulmonary edema, raising ASA levels despite alkalinization

CONTRAINDICATED: Benzos!!! (shifts salicyclates into CNS), urinary alkalinization with diamox

• A 40 year old male is brought in by police after an intentional overdose. The patient smells of EtOH, is belligerent and combative. He is complaining of abdominal pain and the police tell you he vomited in their cruiser on the way to the hospital. The ingestion occurred approximately 2 hours prior to arrival and after some coaxing the patient tells you he took 100 tabs of 325mg Tylenol. He weighs 70kg. Is this a toxic dose? What do you expect the Matthew-Rumack nomogram to advise in terms of giving NAC?

• Phases of Toxicity:
• I: 30 min-24 hrs = N/V, abdominal pain, diaphoresis
• II: 24-72 hrs = elevated LFTs, INR, bilirubin. RUQ pain
• III: 72-96 hrs = hepatic encephalopathy, renal failure, coagulation defects
• IV: 4 d – 2 wks = recovery
• RULE of 150….150 mg/kg = toxic dose = first dose IV NAC (140 if PO) = nomogram number indicating toxicity at 4 hours
• Dx: Matthew-Rumack Nomogram – ONLY IF ACUTE INGESTION
• Tx: NAC

• A 3 year old boy is brought in by his mom for vomiting and abdominal pain. She states he vomited approximately 6 times in about 6 hours and was complaining of abdominal pain. On your evaluation he appears non toxic and is comfortable in the bed playing with his toys. Your exam is largely unremarkable except for tachy mucous membranes. You decide to treat symptomatically and check a KUB. KUB is below. You give him Zofran and a PO challenge and he does not have any additional vomiting episodes. What is your disposition?

Iron

• Must know how much ELEMENTAL Fe
• FeSO4 = 20%....therefore, a 325mg tab has 65mg elemental Fe
• Fegluconate = 12%
• FeFumarate = 33%
• Toxic Dose: >20mg/kg, Lethal dose: >60mg/kg.
• Fe Level > 500 associated with severe toxicity.
• Tx: DeFeroxamine - DON’T give orally

• An 88-year-old man with Parkinson’s disease presents confused. His medication list includes a rivastigmine patch. On evaluation he is confused and appears to have emesis on his clothing, he has significant respiratory secretions that are difficult to control with suctioning. As you undress him to do a full physical exam you find 5 rivastigmine patches. What do you suspect and how do you want to treat it? What is your end goal?

Organophosphate�Carbamate

• DUMBBELS/SLUDGE/Killer B’s
• Types:
• Organophosphates: insecticides (parathion, diazinon), nerve agents (saran, soman, VX)…smells like Garlic
• Carbamates: insecticides (carbaryl), physostigmine
• Muscarine containing mushrooms:Clitocybe, Inocybe
• Tx: 2PAM – Organophos ONLY (MOA: restores acetylcholinesterase)
• Atropine – MOA: anti-cholinergic. Continue until secretions improve & 3 B’s

• A 38-year-old man presents with chest pain for the past hour. He is agitated, diaphoretic, and pupils are dilated. Vital signs are notable for a temperature of 39.1°C, heart rate of 135 and a blood pressure of 210/130. He admits to using illicit substances in the past but “swears” he did not take anything this time prior to the onset of chest pain. An ECG shows sinus tachycardia with ST-segment depression in the lateral leads and a widened QRS. Troponin is elevated at 0.13. 

Sympathomimetic

• CP: CNS stimulation: mydriasis, DIAPHORESIS, flushing, urinary retention, tachycardia, hyperthermia, disorientation, AMS, psychosis (hallucinations – visual or tactile)
• Examples: amphetamines, cocaine, MDMA, Cathinone's (Bath salts)
• Cocaine: Na channel blocker
• Tx: Benzo, benzo, benzo, supportive care, benzo
• Phentolamine for BP

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• A 55-year-old man is brought in from a building fire. He is intubated and receiving 100% FiO₂, but remains hypotensive and tachycardic. His lactic acid is 12 mg/dL. What is the most likely toxin and how do you treat it?

24 y/o male in ED after winning local hot dog eating contest. Complaining of headache, dizziness and skin discoloration beginning 30 minutes ago.

MetHbemia

• MOA: Fe3+ instead of Fe2+ on oxygen molecule, prevents O2 binding
• Fe2 carries O2
• Causes: “-caines”, TMP-SMX, dapsone, aniline, reglan, nitrates
• CP: cyanosis, fatigue, weakness, dizziness, tachycardia, respiratory depression, AMS
• PE: O2 85%, “chocolate colored blood”
• Tx: Methylene blue
• Cx: serotonin syndrome (methylene blue is an MAOI)

A 24-year-old woman presents with her two kids all with the chief complaint of a headache. She states she just left the local children’s hospital where she was told her kids probably just had a viral syndrome. She states everyone in the household has been having frequent headaches over the last few nights. She has been treating with Tylenol at home without relief, describes the headache as diffuse and throbbing. No associated fevers, aura, or photophobia. Her vitals are significant for sinus tachycardia, otherwise they are within normal limits.

• Dx: Carboxyhemoglobin levels
• Nml <5% nonsmoker, <10% smokers
• Tx: OXYGEN
• CO T1/2:
• RA 3-4 hrs
• NRB 90 min
• HBO <30min
• Indications for HBO:
• Seizures, LOC, Coma
• pregnancy CO >15%
• CO >25% anyone
• Persistent symptoms despite treatment
• Evidence of end-organ damage

• A 60 year old male comes in complaining of Flu-like symptoms. States he has been having symptoms for the past few weeks. Complains of fever, chills, nausea, headaches, arthralgias, and cough. States it first started 3 weeks ago on a Monday evening and it lasted about 5 days and his symptoms improved over the weekend but then his symptoms came right back on the following Tuesday. States again they lasted a few days and spontaneously resolved. He has been taking over the counter cough/cold medicine without relief. He states that he just got a new job and really cant afford to miss any days of work. What is the diagnosis? What type of job does this guy likely do? What is the treatment?

Metal Fume Fever

• Acute illness that occurs when fumes from certain metals are inhaled
• Zinc, Copper, Magnesium, Cadmium, Nickel, Brass, Fe, Manganese, Tin
• Common in welders
• CP: fever, chills, excessive salivation, metallic taste, headache, cough, dyspnea.
• S/S may be delayed 4-8 hours after exposure and usually resolve in 24-48 hours
• “Classic”: Flu like illness that starts on Monday, is gone over the weekend and returns on Monday evening in patient that works as a welder or in a shipyard/marina/foundry
• Tx: Supportive, New Job, PRN Bronchodilators

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Quick Review: Osmolar Gap

2Na + glucose/18 + BUN/2.3 + EtOH/4 (memorize this 1 hr before in-service)

Serum Osm – Calculated Osm = Osmolar Gap

• Abnormal if less/greater than -10 or +10

A PIGME Goat – Causes of HIGH Osmolar Gap

• Acetone
• Propylene glycol
• Isopropyl Alcohol (normal AG)
• Glycerol
• Methanol, Mannitol
• Ethylene Glycol
• Gap

HPI: 30yoF p/w ABD pain, N/V, & blurred vision. She reports going out with friends drinking last night and woke up this morning with difficulty focusing her eyes and the “worst hangover of her life”.

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VS: P 120, BP 100/60, RR 28, T 98.6F, SpO2 100% RA

PE: Diffuse ABD ttp w/ signs of surgical abdomen. Bilateral pupils equally dilated and sluggishly reactive. Otherwise normal exam.

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Lab: Na 135, Cl 100, HCO3 4, BUN 60, Cr 1.5, Glu 115, sOsm 380, EtOH 40, UA neg, Upreg neg�

What did this patient most likely ingest?

Methanol

• Found in: windshield wiper fluid, solvents, paint thinners, wood alcohol
• Metabolized to: Formic Acid
• CP: Latent period of 8-30hrs prior to symptom onset. Then ABD pain, N/V, & blurred vision (snowstorm). If severe can cause parkinsonism d/t destruction of basal ganglia.
• PE: Pupils dilated & sluggish to react to light. Hyperemia of optic disc & papilledema.
• Lab Findings: AGMA + High Osmolar Gap, Methanol Level
• Tx: Fomepizole until level < 20, + Folate + HCO3 prn
• HD Indications:
• Level >50
• pH <7.25
• Severe visual or CNS symptoms

An acutely poisoned patient p/w severely depressed level of consciousness and tachypnea. Blood pressure and heart rate are normal. ABG pH 7.23, PCO2 23, HCO3 10. BMP reveals Na 138, K 6.5, Cl 108, HCO3 10, BUN 55, Cr 1.12.

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Which toxic ingestion is most consistent with this presentation?

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1. Isopropyl Alcohol
2. Phenobarbitol
3. Salicylates
4. Ethylene Glycol

Ethylene Glycol

• Found in: Anti-freeze, Brake fluid
• Converted into:
• Glycolic acid → Metabolic acidosis
• Oxalic acid → CaOxalate crystals → Kidney, Brain, Liver Damage
• CP: appears grossly intoxicated with depressed CNS, dyspnea, & headache
• PE: tachypnea, pulmonary edema, dysrhythmias, seizures, facial nerve palsy
• Labs: AGMA, Osmolar Gap, CaOxalate crystals in UA (envelope shaped), Hypocalcemia, EG level.
• Urine may fluoresce w/ woods lamp if within 2 hours of ingestion
• Tx: Fomepizole + Thiamine & Pyridoxine +/- Hemodialysis

50yoM well-known to the ED staff, presents intoxicated. Today, he is belligerent with slurred speech, nystagmus, and an unsteady gait. He is homeless and comes in about once a week intoxicated, so you put him in a room to monitor him until he sobers up. You collect and EtOH level to see how long of a night you are going to have with him, but his EtOH is 5. Concerned about this finding you do a full AMS work up including head CT. His labs are grossly unremarkable and his anion gap is normal.

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What other lab do you want at this point?

What do you suspect he ingested?

Isopropyl Alcohol

• Found in: Rubbing Alcohol, perfume, hand sanitizers
• Metabolized to: Acetone
• CP: Intoxication, CNS depression, abdominal pain, Nausea/vomiting
• PE: Hypotension, hemorrhagic gastritis, Kussmaul respirations
• Fruity breath, Nail polish remover urine
• Lab: NORMAL Anion gap, HIGH Osmolar gap
• Tx: Supportive care
• HD Indications: refractory hypotension, serum level >400-500

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61yoM w/ h/o alcohol abuse was admitted in status epilepticus. He was intubated. His seizures were controlled with IV diazepam and phenytoin. He subsequently develops signs of alcohol withdrawal including agitation, fever, tachycardia, HTN, and tremulousness. This was controlled with frequent boluses of IV diazepam. On hospital day 4, AM labs reveal an AG 31, HCO3 10 mmol/L, and pH 7.17.

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What is causing this patient’s acute worsening of symptoms?

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How would you treat it?

Propylene Glycol

• Odorless, Tasteless
• Found in:
• Solvent for IV drugs … Ativan or Valium IVPB, Phenytoin
• “Pet safe” anti-freeze
• E-cigarette liquid, cosmetics, commercial solvents, textiles, smoke screens
• Metabolized to: lactic acid → pyruvic acid & propionaldehyde
• CP: CNS depression, SIRS syndrome with no septic source, seizures, coma, hypoglycemia, contact dermatitis, hypotension, arrhythmias
• Labs: AGMA, High Osmolar gap, Propylene glycol level
• Tx: Supportive, Discontinue underlying cause, +/- HD, d/w poison control

65yoF presents grossly intoxicated, you have taken care of her many times for acute alcohol intoxication.

Your EtOH 350.

Based on this lab value, approximately how many hours of observation are required for her to be quantitatively sober (ie EtOH <10)?

EtOH Intoxication

• MOA: Increases GABA, Decreases Glutamate
• CP: Euphoria, slurred speech, ataxia, nystagmus
• 4 H’s of severe intoxication:

Hypotension, Hypothermia, Hypoventilation, Hypoglycemia

• Rule out other causes of disease
• Tx: Supportive
• IVF, Thiamine, Glucose, MVI/Folate, +/- Mg & Phos repletion
• Time

Patient is admitted to the ICU for agitated delirium secondary to EtOH withdrawal. He was initially being managed on the floor and treated with 10 mg total IV push Ativan without any improvement in his symptoms. He is aggravated, combative, and unable to be verbally re-directed. He has good IV access.

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How do you want to proceed with treating him?

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EtOH Withdrawal

Varying degrees of withdrawal based on time since last drink

CP: Early: tremor, irritability, tachycardia, hypertension

Seizures: “Rum Fits”, 6-48 hrs of last drink, can be single isolated seizure or multiple brief seizures with rapid recovery in between

• If focal or prolonged post-ictal period search for another cause

Delirium Tremens (DTs): 48-96 hrs after last drink = autonomic hyperactivity (HTN, tachycardia), diaphoresis, visual hallucinations, paranoid ideations

Wernicke Korsakoff: thiamine deficiency → b/l mammillary body destruction.

• Wernicke: ataxia, confusion, ophthalmoplegia
• Korsakoff: psychosis, confabulation, irreversible memory loss

EtOH Withdrawal Treatment

Supportive: IVF, thiamine, glucose, folate/MVI, +/- Mg & Phos repletion

Avoid Antipsychotics: can lower seizure threshold

Benzos: Valium, Ativan, Versed … consider something else

Phenobarbital Monotherapy

• Loading dose 10mg/kg (will reach max effect in 30 minutes)
• Well within therapeutic range (15-40) this loading dose will get level to about 15-16
• PRN dose: 260mg IV q30m for severe s/sx or 130mg IV q30m for mild s/sx

Why? In chronic EtOH abuse brain adapts by ↓GABA receptors & ↑glutamate receptors. Benzos act on GABA only. However, barbiturates ↑GABA & ↓glutamate. Phenobarbital benefits: 1) long ½-life allowing for self-taper, 2) less associated delirium or paradoxical reactions compared to benzos, 3) superior to benzos in seizure prevention

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24 yr old female without any past medical history is brought in by her boyfriend for a possible overdose. He states they were in the middle of breaking up and she went into the bathroom and after 2 hours he went in to see what was going on and found her flushed with really hot skin and she appeared to be having a seizure. Her EKG is below. What toxic ingestion is high on your differential based on this story?

Tricyclic Antidepressants

• Rx: Imipramine, Desipramine, Amitriptyline, Nortriptyline, Doxepin
• MOA: Inhibit re-uptake of monoamines
• S/Sx & Physiologic Effects
• CNS: Confusion/Agitation, Clonus, Choreoathetosis, Convulsions (GABA antagonism), Sedation (Antihistamine)
• Cardiotoxic
• Na & K channel blockage → AV blocks, QRS widening
• Terminal R wave >3mm in aVr
• Pulmonary Edema & Hypotension (Alpha Adrenergic Blockade)
• Anticholinergic
• Flushed, dry, urinary retention, tachycardia, mydriasis, AMS
• Tx: NaHCO3 dosing: 1-2meq/kg. Keep pH<7.55 and serum Na <150
• Seizures: Benzos
• Hypotension: IVF and pressors
• Arrhythmias not broken by NaHCO3 → Lidocaine

A 34-year-old woman with schizophrenia on multiple psychiatric medications presents with tremors and confusion. Her vital signs are unremarkable. Physical examination reveals confusion and hyperreflexia. The patient has a serum sodium of 165 mEq/dl.

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What lab test do you want to get to help in the management of this patient?�

Lithium

• Rx: Bipolar, Schizophrenia
• Acute vs Chronic toxicity
• S/Sx: Nausea/Vomiting/Diarrhea
• Mild: confusion, tremor, fatigue
• Mod: slurred speech, ataxia, hyper-reflexia
• Severe: clonus, hyperthermia, seizures, clonus, Nephrogenic DI
• EKG: bradycardia, TW flattening, QTc prolongation
• Tx: Supportive care and HD
• Indications for HD:
• Seizure
• Worsening clinical condition despite falling lithium levels
• Renal failure
• Level >4 at 6 hours post ingestion acutely (>2.5 chronic ingestion)

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50 year old male BIB EMS for intentional overdose of unknown medication. Patient has history of depression, HTN, HLD, CAD. Patient is vomiting on arrival and appears tachypneic. His VS: 100/80, 40bpm, 26rpm, 97% RA. Labs are significant for pH 6.9, HCO3 10, PCO2 30, and FSG 500. His EKG is below. What is the most likely ingested substance based on these findings

Calcium Channel Blocker

• MOA: Inhibits calcium channel conduction in smooth & cardiac muscle
• CP: Hypotension, Bradycardia, HYPERglycemia, Pulmonary edema, Ileus
• EKG: AV dissociation, Bradydysrhythmias
• Tx:
• Glucagon: 2-5mg IV bolus then 2-5 mg/hr
• Calcium Chloride: 20mg/kg bolus then 20 mg/kg/hr
• High Dose Insulin: 1u/kg bolus then 0.2 – 2.0 units/kg/hr (maintain euglycemia)
• Lipid Emulsion – 1.5 mg/kg bolus then 0.25 mg/kg/hr
• Atropine, Vasopressors
• TV Pacing, Intra-aortic balloon pump, ECMO

A 74-year-old woman with a history of congestive heart failure, hypertension, and coronary artery disease presents with confusion, abdominal pain, and nausea. The patient’s ECG is shown above. She has a potassium of 6.3 mEq/ml. What treatment should be initiated based on this presentation?

Name These Cardiac Glycosides

Cardiac Glycosides (Digitalis Toxicity)

• Causes: Digoxin, Plants
• MOA: Na/K ATPase pump blockade causes ↑intracellular Ca & ↑ heart contractility
• CP: nausea, vomiting, vertigo, blurred (yellow halos) vision, palpitations, syncope
• EKG: Bradycardia with AV block, Bidirectional Vtach, Slow Afib
• “Salvador dali mustache” – digitalis effect, not necessarily toxicity
• Labs: Hyperkalemia
• Tx: Dig Fab – given if: CVS collapse, Conduction abnormalities, K>5.5, Digitalis level >10
• AVOID:
• K or Mag replacement
• Cardioversion or Pacing → can induce ventricular dysrhythmias
• Calcium ???
• Beta Blockers, CCB

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A 20-year-old man presents after a suicide attempt. He is lethargic and moans to painful stimuli. His pupils are 2 mm bilaterally. Vital signs are BP 80/40; HR 58; RR 5 and saturation 92%. What is the most likely ingested medication?

Clonidine

• MOA: Centrally acting alpha2 agonist → reduces SNS tone to heart and peripheral blood vessels
• Initially causes hypertension followed by anti-hypertensive effects
• Withdrawal: severe headache, rebound HTN
• OD CP: mimics opioids … apnea, AMS, seizures, miosis, hypotension, bradycardia
• Tx: Supportive care, Narcan (variable success), need high doses (10-20mg IV)

A 65-year-old man presents with generalized weakness. He has a history of hypertension. His vital signs are BP 77/40, HR 34. His ECG is shown below. FSG 50. Physical examination reveals a confused patient with bradycardia. What toxic ingestion are you suspecting?

Beta Blocker

• Which BB is the WORST to overdose on?
• Propanolol
• CP: 4 H’s
• Hypotension
• Hypoglycemia
• Heart Rate Decreased or Heart block (Bradycardia)
• Hypocerebrum (Depressed LOC)
• EKG: Na/K channel blockage → wide QRS, long QTc
• Tx:
• Same as CCB

Biz Buzz Mushroom Poisoning

• Looks like Tylenol poisoning?
• Presents with seizures?
• Cholingeric crisis?
• Disulfiram Reactions?
• Ataxia, visual hallucinations, hyperkinesis?
• Presents with N/V/D within 6 hours?

BITES AND STINGS

Heat Cold

• Heat Exhaustion - 37-40C
• Intense thirst, anxiety, dizzy, weak, syncope
• Heat stroke - >40C - CNS changes = Encephalopathy, Ataxia, Delirium, Seizures
• Labs: Elevated LFT, DIC, Rhabdo
• Classic - Old - Hot, Dry Skin
• Exertional - Younger - Profuse Sweating
• Tx: Rapid cooling to 38-39C rectal
• Best - CWI (Conduction)
• Most practical - Spray/Fan (Evaporative)
• ECMO, Lavage prn, support MSOD
• ***TYLENOL IS POINTLESS***

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• Chilblains - mild tissue injury, painful/inflamed itchy red skin
• Trench Foot - Wet cold - cold, mottled, pale feet , hyperhidrosis
• Frostnip - superficial freezing - superficial blistering and peeling may occur -- reversible
• Frostbite: Irreversible
• 1st- Parital skin freezing - central white plaque, surrounding erythema, stings/burn/throb
• 2nd- Full thickness - Clear blisters, Numb → throbbing, Desquamation/Eschar over days
• 3rd- Tissue loss, Hemorrhagic blisters, “block of wood → burning, shooting. Skin necrosis
• 4th- Extends to SQ/muscle/bone → deep aching pain, mottled skin with non-blanching cyanosis and deep, dry eschars
• Tx: Rewarming (painful!), H2O 37-39C (98.6-102.2F)
• DON’T thaw if any chance of refreezing
• Aspirate clear blisters or leave intact
• When should you aspirate hemorrhagic blisters?

HYPOTHERMIA: Temp <35C = 95F

• Staging:
• I/Mild - 32-35C (90-95) → Shivering, Awake → Passive External
• II/Mod - 28-32C (82-90) → AMS, Arrhythmia, shivering ceases → Active External
• III/Severe - 20-28 (68-82) - Unconscious, → Active Internal
• IV/Profound - <20C (68F) - VS unobtainable → Same as III + ACLS
• EKG: J wave/Osborn Wave, TWI, Prolong Intervals, AVB,
• A fib with Brady → V fib → Asystole
• Tx: Handle gently, Rewarm
• Accurate temp - internal monitoring
• Drugs can be ineffective!
• Rewarm to 30-32C → before Defib, Epi, Pacing, etc.
• Exception: Can Defib x 1
• Modified ACLS → 3 Defib and 3 epi once temp >30C vs 3 defib + Epi when >30 then Epi Q6 until >35 vs Defib + Epi then warm 5C then repeat prn
• Treat Dysrhythmias with rewarming
• Cx: AB disoders, Core Afterdrop, Dysrhythmias, DIC, Pancreatitis, VTE, Rhabdo
• Not dead until Warm and Dead (>30-32C) EXCEPT:
• K>10-12
• Rigor mortis
• Asystole >32C

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Electrical Injuries

• Tissue Resistance: Nerve<Blood<Muscle<Skin<Tendon<Fat<Bone
• AC - household current
• VF (5-100mA)
• 6-9 mA → let go threshold
• DC - high voltage power lines, lightening
• Asystole
• Extensive internal tissue damage
• Throws the victim
• Lightening:
• Very brief exposure
• Asystole resolves spontaneously however diaphragm usually still paralyzed → hypoxia and VF
• Ruptured TM , Cataracts
• Pupils fixed due to ciliary body paralysis
• Lichtenberg figures and Keraunoparalysis
• Reverse Triage!
• Tx:
• Low voltage (<1000V) → Asymptomatic, Sent home
• Normal EKG, no cardiac complaints
• High voltage → Admit

Burns

• Rule of 9s
• Degree:
• 1st - Sunburn
• 2nd - Superficial or Deep - Blisters
• 3rd - Full thickness - White/Leathery
• 4th - MSK/Bone/Tendon injury
• Tx: Parkland - 4ml x kg x %BSA
• 2nd+ degree only
• Give ½ in first 8 hours, next half over next 16 hours
• LR fluid of choice, UOP > 1ml/kg/hr
• +MIVF in kids
• Intubate early if inhalational injury
• Escharotomy prn circumferential burns
• Singed nasal hairs, soot in mouth, enclosed space
• ***Alternative = Rule of Palms****

Altitude Illness

1. AMS
1. Altitude>8000ft
2. CP: Hangover
3. Tx: no further ascent until acclimatized, acetazolamide, Decadron
2. HAPE
• Non cardiogenic pulmonary edema
• 2-4 days after ascent
• CP: AMS symptoms, Cough, Dyspnea at rest, Fever, Rales, Pink Sputum
• CXR: RML infiltrate
• Tx: Descent, O2, Nifedipine
• MCC Death
3. HACE
• 2-4 days after ascent, >12k
• CP: Ataxia, AMS, 3rd/6th CN palsies
• Tx: Descent, O2, Decadron, Furosemide or Mannitol

DYSBARISM

1. Barotrauma of DESCENT
1. Squeeze Syndromes
1. Barotitis Media: “Ear squeeze” → pain from mmHg on TM
1. If TM ruptures → Vertigo, N/V
2. Tx: Nasal decongestants, Valsalva
2. Other squeezes: Sinus squeeze, face mask squeeze, eye squeeze, suit squeeze, lung squeeze, barodentalgia
2. External ear barotrauma -- d/t blockage of EAC by cerumen or ear plugs
3. Inner ear barotrauma -- hemorrhage or rupture of the inner ear round window with sensorineural hearing loss = labyrinthine window rupture
• Severe vertigo, N/V,tinnitus, nystagmus, ataxia
• Tx: Referral to ENT
2. Barotrauma of ASCENT
• Pulmonary Barotrauma - Pulmonary Over Pressurization Syndrome (POPS)
• Rapid uncontrolled ascent (Boyle’s Law)
• Expansion of unvented lung gases on ascent results in a “burst lung” -- pulmonary overpressurization causes alveolar gas to enter systemic circulation
• CP: PTX, pneumomediastinum, pneumopericardium, HTX from injured lung, AGE
• Tx: HBO
• DCS, Arterial Gas Embolism
• Facial Baroparesis (Bell’s Palsy)
3. Dysbarism at depth
• Nitrogen Narcosis → Depth > 100ft
• CP: AMS, hallucinations, poor judgement Tx: Slow Ascent
• O2 toxicity
• CP: Seizures, blurred vision, tinnitus confusion Tx: Slow Ascent

Decompression Sickness

1. Disorder of ASCENT (gas comes out of solution)
1. Typically start within 3 hours, 98% within 24 hours of ascent
1. EXCEPT CNS → 10 min
2. Tx: Recompression in a chamber (HBO)
3. Type I DCS
• Pain only
• Affects musculoskeletal, skin, lymphatics → The Bends” or “Caisson’s Disease”
• Periarticular pain (especially elbows and shoulders) in 70% of all cases
• Pruritus, erythema, skin marbling (“cutis marmorata”) from venous stasis
4. Type II DCS
• CNS, Serious!
• Spinal DCS -- Ascending paralysis, Limb paresthesias, weakness, dermatome sensory distribution is common, Incontinence, priapism
• Headache, diplopia, dysarthria, inappropriate behavior
• The staggers, The chokes
5. Arterial Gas Embolism (Type III) - can result from POPS and DCS
• Presents within 2 min of surfacing
• CP: Acute LOC, CVA symptoms, blindness, seizures, immediate death
• Tx: Rapid recompression/HBO, IVF

Drowning

• Types:
• Non-fatal → process of drowning interrupted
• Fatal - death
• Leading cause of accidental death in children
• Shock is rare in drowning
• If in shock → rule out trauma
• C spine precautions
• Mammalian diving reflex → Babies/Kids
• Sudden cold water immersion → shunt blood to CNS & Decrease metabolism
• Bradycardia, Apnea
• Survival → time, temperature, age, associated trauma, bystander CPR
• Tx: Supportive care
• If good O2 and stable after monitoring can DC to home

Blast Injury

• Primary → Barotrauma from blast wave
• Gas filled structures → TM rupture, PTX, Hollow viscus rupture
• Secondary → Flying Debris
• Penetrating trauma
• Tertiary → Flying People
• Deceleration impact
• Quaternary → Misc/Chronic conditions → Toxic gases, radiation, burns, crush injuries

Acute Radiation Syndrome

• Radiation dose >0.7Gy (70 rad)
• High energy gamma rays, neutrons or protons, typically whole body exposure
• Stages:
• Prodrome -- N/V/D, Conjunctivitis (min-dys)
• Latent -- Feels better (hrs-wks)
• Manifest Illness Stage - Syndromes Appear (Dys-Mo)
• Syndromes:
• Hematopoietic -- .7-10 Gy (70-1000 rad)
• Pancytopenia → Infection, Hemorrhage
• Gi -- 6-10 Gy (600-1000 rad)
• Severe diarrhea, fever, dehydration, electrolyte imbalances, abd pain
• Survival unlikely, death w/in 2 weeks
• CV/CNS - 20+ Gy (2000+ rad)
• Convulsions, Coma, Arrhythmia, LOC, Papilledema, Ataxia
• Non-survivable, Death w/in 3 days of >50Gy (5000 Rad)
• Recovery or Death (wk-yrs)
• Dx: ALS @ 48 hours
• >1200 = Will likely Recover
• <1000 = Severe injury
• <300 = Lethal

Biologic Weapons

• Bacterial:
• Anthrax: Cutaneous, Inhalational, GI
• Inhalational: Fever, drenching sweats, fatigue, cough, N/V, chest pain → Sepsis → Death
• Wide mediastinum on CXR
• Tx: Ciprofloxacin or Doxycyline
• PPX: Vaccine, Cipro
• Cutaneous - pruritic papule → vesicle → ulceration → eschar
• Tx: Same, but abx but not alter course
• Cholera
• Plague - Yersinea Pestis -- rodent fleas
• Pneumonic - fever, hemoptysis, shock, DIC, transaminitis. Needs isolation
• Tx: Streptomycin, Doxycycline, Chloramphenicol. PPX: Vx
• Bubonic - Buboes, fever, HA, chills. No person-person spread
• Tularemia
• Viral
• Smallpox - Variola, Airborne transmission, Not contagious until rash, Lesions all in same stage development
• PPX: Vx
• Viral hemorrhagic fever
• Toxins
• Botulinum -- aerosolized, highly lethal
• Inhibits Ach release → symmetric descending paralysis, CN palsy. Bulbar symptoms, respiratory failure
• Tx: Supportive, Anti-toxin +/- BIG
• Ricin - Castor bean mash -- cytotoxin, airway necrosis, hemorrhagic pulmonary edema.

Chemical Weapons

• Vesicants
• Mustard - large necrotic blisters
• Phosgene - pulmonary edema, Skin wheal/blanch, smells like wet hay
• Lewisite - immediate pain, increased capillary permeability → Shock/MODS
• Nerve agents
• Tabun, Sarin (most volatile), Soman, Vx (most potent) → Organophosphates
• Cyanide
• Riot control: Tear gas, Pepper spray