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ER46 Emergency Medicine
Environmental Injuries
Toronto Notes 2019
Anterior
18% %%
1%
9% 9%
41⁄2 %
41⁄2 18% 41⁄2 %%
9% 9%
Figure 14. Rule of 9s for total BSA
• activeexternalre-warming
■ involves use of warming blankets
■ beware of “afterdrop” phenomenon
■ safer when done in conjunction with active core re-warming
• activecorere-warming
■ generally for patients with core temperature <32.2°C, and/or with cardiovascular instability ■ avoids “afterdrop” seen with AER alone
■ re-warmcorebyusing
◆ warmed humidified oxygen, IV fluids
◆ peritoneal dialysis with warm fluids
◆ gastric/colonic/pleural irrigation with warm fluids
◆ external circulation (cardiopulmonary bypass machine) is most effective and fastest
Approach to Cardiac Arrest in the Hypothermic Patient
• doallproceduresgentlyormayprecipitateVFib
• checkpulseandrhythmforatleast1min;mayhaveprofoundbradycardia
• ifanypulseatall(evenveryslow)doNOTdoCPR
• ifinVFibtrytodefibrillateuptomaximum3shocksifcoretemperature<30°C
• intubateifrequired,ventilatewithwarmed,humidifiedO2
• medications(vasopressors,antidysrhythmics)maynotbeeffectiveatlowtemperaturescontroversial;
may try one dose
• focusoftreatmentisre-warming
FROSTBITE
Classification
• icecrystalsformbetweencells
• classifiedaccordingtodepth–similartoburns(1stto3rddegree) • 1stdegree
■ symptoms: initial paresthesia, pruritus
■ signs: erythema, edema, hyperemia, no blisters • 2nddegree
■ symptoms: numbness
■ signs: blistering (clear), erythema, edema • 3rddegree
■ symptoms: pain, burning, throbbing (on thawing); may be painless if severe
■ signs: hemorrhagic blisters, skin necrosis, edema, no movement • 4thdegree
■ extension into subcuticular, osseous, and muscle tissues
Management
• treatforhypothermia:O2,IVfluids,maintenanceofbodywarmth
• removewetandconstrictiveclothing
• immersein40-42°Cagitatedwaterfor10-30min(verypainful;administeradequateanalgesia) • cleaninjuredareaandleaveitopentoair
• consideraspiration/debridementofblisters(controversial)
• debrideskin
• tetanusprophylaxis
• considerpenicillinGasfrostbiteinjuryhashighriskofinfection
• surgicalinterventionmayberequiredtoreleaserestrictiveeschars
• neverallowathawedareatore-chill/freeze
Burns
• seePlasticSurgery,PL18
Clinical Presentation/Physical Exam Findings
• burnsize
■ rule of nines; does not include 1st degree burns
• burndepth
■ superficial (1st degree): epidermis only (e.g. sunburn), painful and tender to palpation
■ superficial partial thickness (2nd degree): extends to epidermis and superficial dermis, blister
formation occurs, very painful
■ deep partial thickness (2nd degree): involves hair follicles, sebaceous glands; skin is blistered,
exposed dermis is white to yellow, absent sensation
■ full thickness (3rd degree): epidermis and all dermal layers; skin is pale, insensate, and charred or
leathery
■ deep (4th degree): involvement of fat, muscle, even bone
Management
• removenoxiousagent/stopburningprocess
• establishairwayifneeded(indicatedwithburns>40%BSAorsmokeinhalationinjury) • resuscitationfor2ndand3rddegreeburns(afterinitiationof2largeboreIVs)
41⁄2 %
41⁄2
41⁄2
Posterior
© Erina He 2016