Environmental Emergencies II Nicholas E. Kman, MD FACEP Associate Professor The Ohio State University Department of Emergency Medicine
Transcript
Environmental Emergencies II
Nicholas E Kman MD FACEPAssociate ProfessorThe Ohio State UniversityDepartment of Emergency Medicine
ObjectivesLearner will review the following EmergenciesSnake EnvenomationsSpider BitesMarine EnvenomationsDrowningDysbarismDive MedicineHigh Altitude Illness
Guess That Movie Line
>
null
13270155
Snake Envenomations
Wikimedia
Snake Bites
Snake Bites
9000 snakebites annually in US with 2000 treated as envenomations
Est 25 million venomous snakebites occur internationally with 125000 deaths annually
About 12 deathsyear in US60 rattlesnakesImportant to know distribution of venomous snakes in your area
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
ObjectivesLearner will review the following EmergenciesSnake EnvenomationsSpider BitesMarine EnvenomationsDrowningDysbarismDive MedicineHigh Altitude Illness
Guess That Movie Line
>
null
13270155
Snake Envenomations
Wikimedia
Snake Bites
Snake Bites
9000 snakebites annually in US with 2000 treated as envenomations
Est 25 million venomous snakebites occur internationally with 125000 deaths annually
About 12 deathsyear in US60 rattlesnakesImportant to know distribution of venomous snakes in your area
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Snake Bites Treatments to AvoidTx to Avoid in (Pit Viper) Snakebite
Cutting andor suctioning of woundIceNSAIDsProphylactic antibiotics or fasciotomyRoutine use of blood productsShock therapy (electricity)Steroids (except for allergic phenomena)Tourniquets
Lavonas et al BMC Emergency Medicine 2011 112
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Snake Bite ED ManagementNotify Regional Poison CenterABCrsquosAt least 1 IV line draw labs while startingIf no signs of envenomation observe 8 hours for further progression
Measure circumference of limb mark leading edge every 15-30 minutes
If signs of envenomation antivenin admin
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
SNAKE BITESOvine (Sheep Derived) Fab Antivenin (CroFab)Mix 4-6 vials in 250ml of NSAdditional 4-6 vials until control achievedScheduled 2-vial doses at 6 12 and 18 hrInitial dose given slowly for first 10 minRest of dose over 1 hr
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Snake Bite Complications
Compartment syndrome ndash surgery is rarely indicated if worried do pressure monitoring
Serum sickness (type III hypersensitivity) ndash up to 3 weeks after antivenin fever chills arthralgias diffuse rash
Rx-steroids and antihistamines
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
QuizA 23 year old male was playing with a copperhead
when he was surprisingly bit He had premedicated with about ldquoeleventeenrdquo beers He is complaining of severe pain spreading edema and has mild hypotension What is the best treatment
A Lecture on the dangers of mixing snakes and alcohol
B 4 Vials of CroFab AntiveninC 2 Vials of Horse Serum Derived AntiveninD Applying oral suction to the bite site
Name the Actor
>
null
54857273
Spider Envenomations
Ohiorsquos Biting Spiders
2 main groups of spiders the recluse spiders and the widow spiders
The black widow Latrodectus mactans and the northern widow Latrodectus variolus
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Black Widow
bull Initial bite may be no more than a prickbull Within 30 min ndash systemic symptomsbull Muscle cramping ndash local to large groups such as abdomen back chest thighs
bull Nausea vomiting
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Black WidowMay mimic an acute abdomenHypertension tachycardiaLatrodectus facies ndash spasm of facial muscles edematous eyelids
Priapism weakness diaphoresis fasciculations may all occur in severe envenomation
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
TreatmentIce to bite sitePain medicationBenzodiazepines for muscle spasmCalcium gluconate no longer recommendedTetanus prophylaxisAntivenin ndash for severe symptoms not relieved by above measures esp hypertension pregnancy
Brown Reclusebull Loxosceles reclusabull Coast to coastbull Attics closets woodpiles storage shedsbull Violin-shaped markingbull Cytotoxicbull Necrotic arachnidismbull Local and systemic effects
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Cutaneous LoxoscelismInitially a sharp stinging sensation some report no awareness of being bitten
Over 2-8 hrs aching and itching developBulls-eye lesion erythema surrounds vesicle circumscribed by a ring or halo of pallor
Necrosis may develop within 3-4 days becoming ulcerated
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Brown Recluse Venom
Cytotoxic enyzmes cause destruction of local cell membranesAlkaline phosphatase5-ribonucleotide phosphohydrolaseEsteraseHyaluronidaseSPHINGOMYELINASE D
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Brown Recluse
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
TreatmentImmobilization ice elevationTetanus prophylaxisAntihistaminesDapsoneSkin grafting once area has demarcatedAntivenin - research
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Systemic LoxoscelismRarely correlates with the severity of the skin lesion
Children most at riskFever chills myalgias arthralgias morbilliform rash
DIC seizures renal failure hemolysisSteroids may decrease amount of hemolysisAlkalinize urine
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
QuizA 19 year old male is reaching into a tackle box when he feels a prick He thought he poked himself with a fishing lure but becomes nauseated and presents complaining of severe abdominal pain On exam his abdomen is rigid and tender What is the next best treatment
A Exploratory LaporatomyB Calcium GluconateC DapsoneD Analgesics and Benzos for muscle spasm and pain
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Seabatherrsquos eruption ndash intensely pruritic maculopapular eruption on skin that has been covered by swimwear ndash larvae of thimble jellyfish develops within 24 hrs of exposure and lasts 3-5 days
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Treatment
ABCs
Inactivate nematocysts
Remove
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Jellyfish TreatmentRinse with saltwaterRemove tentacles with protected handPour acetic acid (vinegar) on it to inactivate the nematocystsUntil pain ceasesUse isopropyl alcohol if vinegar not available
Scrape off nematocystsMay then use ice to decrease painEvacuate patients with continued symptoms or suspected box jellyfish envenomation
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
RemovalWear gloves for protectionApply shaving cream baking soda pasteShave with razor or other sharp edgeTetanus prophylaxisAntihistaminesWatch for infection
httpwwwprwebcomreleases201110prweb8913589htm
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Echinodermsbull Sea urchins starfish sea cucumbersbull Venoms usually contained in spinesbull Local effects most common bull Systemic effects do occurbull Deaths are extremely rare
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Echinoderms
Remove visible spinesImmersion in hot water for 30-90 minutesLocal or regional anesthesia if hot water alone is not adequate
X-ray or ultrasound to look for retained fragments ndash surgery may be needed
Tetanus prophylaxisWatch for infection
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Quiz A patient presents to your emergency department after being
stung by a jellyfish At the scene life guard treated with wound with urine shaving cream vinegar sea water and taco sauce What is the next best treatment
A Local wound care and tetanus prophylaxis B More urine C Vinegar mixed with shaving cream D Cold Tap Water
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Drowning
Wikimedia
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
LLSA Szpilman D Bierens J Handley A Orlowski J Drowning N Engl J Med 2012366(22)2102-10
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
TerminologyDrowning Process resulting in respiratory impairment
from submersion immersion in liquid medium Victim may live or die during or after process The outcomes are classified as death morbidity and no morbidity
The Drowning Process A continuum that begins when the victimrsquos airway lies below the surface of liquid usually water preventing the victim from breathing air
Drowned refers to a person who dies from drowning
DrowningSecond only to MVA as most common cause of accidental death in US
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Pulmonary Over-Pressurization
A too-rapid ascentLung emptying is incompleteLung volume expands rapidlyPneumothorax pneumomediastinum SQ emphysema rupture into pulmonary vein causing air embolism
Simple pneumothorax may progress to tension on further ascent
Arterial Gas Embolism (AGE)Results from air bubbles entering pulmonary venous circulation from ruptured alveoli
Usually develops right after diver surfacesSudden LOC on surfacing should be considered an air embolus until proven otherwise
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
AGE
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Arterial Gas Embolism (AGE)
Recompression in hyperbaric chamberTransport supine not in Trendelenburg100 oxygen intubate if necessaryIVFAspirin for antiplatelet activity if not bleeding
Transport in plane pressurized to sea level or helicopter no higher than 1000 ft above sea level
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Decompression Sickness (DCS)Henryrsquos Law ndash amount of gas that will dissolve in a liquid
is proportional to partial pressure of gas over the liquidNitrogen equilibrates through the alveoli into the blood
but is 5 times more soluble in fatThe longer and deeper the dive the more nitrogen gas
will be accumulated in the body
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Decompression SicknessDuring a slow ascent pressure decreases nitrogen in the tissues is released into blood and alveoli
If ascent is too quick gas comes out of solution and forms gas bubbles in the blood or tissue
Type I ndash extravascular gas bubblesType II ndash intravascular nitrogen gas emboli
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Type I DCSldquoThe Bendsrdquo ndash periarticular joint pain is most common symptom of DCS
Shoulders and elbows most often affectedDull deep ache mild at first and becomes more intense
Palpable tendernessVague area of numbness around the affected joint
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Type I DCSCutaneous ndash pruritus cutis marmorata hyperemia orange peel
LymphedemaFatigue especially if severe
Vann RD Butler FK Mitchell SJ Moon RE ldquoDecompression illnessrdquo The Lancet v 377 issue 9760 2011 p 153-64
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Type II DCSPulmonary system (The Chokes)Nervous system (The Staggers)Decompression shock
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Cerebral AGE vs DCS II
DCS IIDive must be long
enough to saturate tissues
Onset is latent (often 2-6 hrs)
Spinal cord and brain
Cerebral AGEMay occur after any
type of diveOnset is immediate
(lt10-120 min)Only brain
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Pulmonary DCS
ldquoThe ChokesrdquoMay begin immediately after dive but often takes up to 12 hours to develop
Triad ndash shortness of breath cough and substernal chest pain or chest tightness
Cyanosis tachypnea and tachycardia
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Neurologic DCS
Spinal cord is the most common site affectedLower thoracic and lumbar regionsLow back pain ldquoheavinessrdquo in legs paresthesias possible bladder or anal sphincter dysfunction
Brain ndash variety of symptoms and difficult to distinguish from AGE
Scotomata headache confusion dysphasia
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Decompression ShockVasomotor decompression sicknessRapid shift of fluid from intravascular to extravascular spaces (unknown reason)
Rare but often lethalWeakness sweating hypotension tachycardia pallor
Despite fluids hypotension may not respond until recompression
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
DCS Diagnostics
History is most importantLab used to rule out other conditions andor obtain baseline measurements
CXRECGCTMRITesting should not delay transfer to HBO
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
DCS Treatment
ABCsTransport supine not Trendelenburg100 oxygenIVFRecompression therapyDivers Alert Network (DAN) 919-684-811175-85 have good results when recognition and treatment are prompt
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Photo N Kman
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
QuizYou are on a plane from Key West to Cleveland
when the passenger next to you starts to arch his back and bend his knees He then starts to rapidly breath and call for the flight attendant She asks ldquois there a doctor on the planerdquo What do you do
A Lecture the passenger on diving too close to a flight
B Start high flow O2 keep the patient supine and get the patient to a hyperbaric chamber upon landing
C Intubate and hyperventilate
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
High Altitude Medicine
httpphilcdcgovphildetailsasp
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
High Altitude IllnessRate of ascent
Altitude reached
Sleeping altitude
Individual physiology
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
High Altitude IllnessRate of ascent Graded ascent is safest to facilitate acclimatization and prevent sickness
Altitude reached AMS usually seen at altitudes in gt 2000 meters (6560 ft) and caused by hypobaric hypoxia
Sleeping altitude Increases gt600 meters in sleeping altitude should be avoided
Individual physiology Age gender and fitness level do NOT play a role in susceptibility to altitude illness
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Risk Factors
History of high altitude illnessResidence at altitude below 900 mExertionPreexisting cardiopulmonary conditionsAge lt 50 yearsPhysical fitness is not protectiveMedications
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
High Altitude Medicine
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Acute Mountain SicknessHistory is key (total elevation gain and rate of gain)
Starts within hours and can last for daysAMS is present if at altitude and in addition to headache at least one of following is presentDizziness or lightheadednessFatigue or weaknessNauseavomitinganorexiaInsomnia
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
AMS
Hypoxia=The hypoxic-ventilatory response Neurohumeral and hemodynamic responses
Overperfusion of microvascular bedsElevated hydrostatic capillary pressureCapillary leakageConsequent edema
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
AMSAvoid further ascent until symptoms have resolved
Descend if no improvement in 24 hours or worsening symptoms
Non-narcotic pain relievers for headacheSupplementary oxygenAcetazolamide dexamethasoneGamow bag
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Acetazolamide
For both treatment and prevention of AMSMechanism of action increase urinary excretion of
sodium potassium and bicarbonate resulting in a hyperchloremic metabolic acidosis which stimulates ventilation improving arterial oxygen saturation
Decreases periodic breathing and improves sleeping
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Acetazolamide
Speeds up acclimatization250 mg po bid for treatment125-250 mg po bid starting 24 hr before ascent
and the first 2 days at high altitude
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Dexamethasone
For treatment or prevention of AMSDoes NOT speed up acclimatizationMay improve integrity of blood-brain barrier thereby reducing edema
4 mg po every 6 hrs for treatment4 mg po every 12 hrs for prevention
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Other TreatmentsGinko Biloba (120mg PO BID starting 5 days prior
to ascent)-modest evidenceProphylaxis against HAPE
Nifedipine 20mg PO q8 for patients with recurrent HAPE
Salmeterol-effective in reducing risk of HAPE in those with recurrent episodes
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
Golden Rules of AMS
0 Itrsquos ok to get AMS Itrsquos not ok to die of it
1 Any illness is AMS until proven otherwise
2 Never ascend with AMS symptoms
3 If you are getting worse go down at once
4 Never leave someone with AMS alone
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
High Altitude Cerebral Edema (HACE)
HACE progression of AMS to life-threatening end-organ damage
Defined as severe AMS symptoms with additional obvious neurologic dysfunctionAtaxiaAltered level of consciousnessSevere lassitude
HACE almost never occurs without antecedent AMS symptoms as a harbinger
The progression of AMS to coma typically occurs over 1 ndash 3 days
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
HACE
Progression of AMSAtaxia is the single most useful signDiffuse neurologic dysfunctionAltered mental status nausea vomiting seizures decreased LOC coma and finally death
Once coma present ndash 60 mortality rateCause of death ndash brain herniation
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
High altitude retinal hemorrhage generally occurs at gt 17000 ftUV Keratitis delayed onset of symptoms (hours)
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
HACE Treatment
DescendDescend Descend OxygenDexamethasone 8 mg load followed by 4 mg every 6 hrs
Gamow bag if descent not possible
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
HAPE
Accounts for most deaths from high altitude illness
Non-cardiogenic pulmonary edemaCommonly strikes the second night at a new altitude
Rarely occurs after more than four days
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
HAPEEarly diagnosis is crucial to recoveryDecreased exercise performanceDry cough initiallyTachycardia and tachypnea at restDyspnea at restRales typically originate in right axilla and become bilateral as illness progresses
Cerebral signs and symptoms are common
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
HAPE
Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
HAPEPulmonary hypertension due to hypoxic pulmonary vasoconstriction
Elevated capillary pressureStress failure of pulmonary capillaries as a result of high microvascular pressure is the presumed final process leading to extravasation of plasma and cells
Impaired clearance of fluid from alveolar space probably has a role
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure
High Altitude Cerebral Edema (HACE)HeadacheDisorientationLoss of coordinationMemory lossPsychotic behaviorComa
High Altitude Pulmonary Edema (HAPEChest tightnessPersistent coughFrothy sputumFeeling of impending suffocationDuring sleep
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Quiz You decide to climb to the top of Mt Everest While nearing
the top your partner begins to have a seizure and becomes unresponsive What is the best treatment for him
A Prednisone taper B Acetazolamide IV C High Flow Oxygen D Descent
Questions
Environmental Emergencies II
Objectives
Guess That Movie Line
Snake Envenomations
Slide 5
Snake Bites
Snake Bite Statistics
Snake Bites (2)
Coral Snake (Elapidae)
Slide 10
Coral Snake (Elapidae) (2)
Coral Snake (Elapidae) (3)
Slide 13
Signs and Symptoms
Snake Bites (3)
Moderate
Severe
Slide 18
Snake Bite Management
SNAKE BITES
Snake Bites Treatments to Avoid
Snake Bite ED Management
SNAKE BITES (2)
Snake Bite General Wound Care
Snake Bite Complications
Quiz
Quiz (2)
Name the Actor
Slide 29
Spider Envenomations
Ohiorsquos Biting Spiders
Widow Spiders
Black Widow
Black Widow (2)
Treatment
Brown Recluse
Cutaneous Loxoscelism
Brown Recluse Venom
Brown Recluse (2)
Treatment (2)
Systemic Loxoscelism
Quiz (3)
Quiz (4)
The Deep Blue Sea
The Deep Blue Sea (2)
Marine Envenomations
Jellyfish
Jellyfish (2)
Slide 49
Slide 50
Jellyfish (3)
Treatment (3)
Jellyfish Treatment
Removal
Echinoderms
Echinoderms (2)
Quiz (5)
Quiz (6)
Drowning
Slide 60
Terminology
Drowning (2)
Drowning Pathophysiology
Drowning Treatment
Predictors of Outcome
Diving Medicine
Dysbarism
Types
Slide 69
Boylersquos Bubbles
Middle Ear Squeeze
Middle Ear Squeeze (2)
Other Barotrauma
Pulmonary Over-Pressurization
Arterial Gas Embolism (AGE)
AGE
Arterial Gas Embolism (AGE) (2)
Decompression Sickness (DCS)
Decompression Sickness
Type I DCS
Type I DCS (2)
Type II DCS
Cerebral AGE vs DCS II
Pulmonary DCS
Neurologic DCS
Decompression Shock
DCS Diagnostics
DCS Treatment
Slide 89
Quiz (7)
Quiz (8)
High Altitude Medicine
High Altitude Illness
High Altitude Illness (2)
Risk Factors
High Altitude Medicine (2)
Acute Mountain Sickness
AMS
AMS (2)
Acetazolamide
Acetazolamide (2)
Dexamethasone
Other Treatments
Golden Rules of AMS
High Altitude Cerebral Edema (HACE)
HACE
Slide 107
Slide 108
HACE Treatment
Slide 110
HAPE
HAPE (2)
HAPE (3)
HAPE (4)
HAPE Treatment
Slide 116
Quiz (9)
Quiz (10)
Questions
HAPE Treatment
Descent is treatment of choiceExertion may worsen the illnessOxygenGamow bag if unable to descendNifedipine 10 mg po initially then 20-30 mg extended release every 12 hrs ndash decreases pulmonary artery pressure