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ER48 Emergency Medicine
Environmental Injuries Toronto Notes 2019
• culturewoundifsignsofinfection(erythema,necrosis,orpus);obtainanaerobicculturesifwoundfoul smelling, necrotizing, or abscess; notify lab that sample is from bite wound
• suturing
■ vascular structures (i.e. face and scalp) are less likely to become infected, therefore consider suturing ■ allow avascular structures (i.e. pretibial regions, hands, and feet) to heal by secondary intention
• tetanusimmunizationif>10yrorincompleteprimaryseries
Prophylactic Antibiotics
• typesofinfectionsresultingfrombites:cellulitis,lymphangitis,abscesses,tenosynovitis,osteomyelitis, septic arthritis, sepsis, endocarditis, meningitis
• a3-5dcourseofantibioticsisrecommendedforallbitewoundstothehandandshouldbeconsidered in other bites if any high-risk factors present
• dogandcatbites(pathogens:Pasteurellamultocida,S.aureus,S.viridans) ■ 10-50% of cat bites, 5% of dog bites become infected
■ 1st line: amoxicillin + clavulanic acid
• humanbites(pathogens:Eikenellacorrodens,S.aureus,S.viridans,oralanaerobes)
• 1stline:amoxicillin+clavulanicacid
• rabies(seeInfectiousDiseases,ID20)
■ reservoirs: warm-blooded animals except rodents, lagomorphs (e.g. rabbits) ■ post-exposure vaccine is effective; treatment depends on local prevalence
INSECT BITES
• beestings
■ 5 types of reactions to stings (local, large local, systemic, toxic, unusual)
■ history and physical exam key to diagnosis; no lab test will confirm
■ investigations: CBC, electrolytes, BUN, Cr, glucose, ABGs, ECG
■ ABC management, epinephrine 0.1 mg IV over 5 min if shock, antihistamines, cimetidine 300
mg IV/IM/PO, steroids, β-agonists for SOB/wheezing 3 mg in 5 mL NS via nebulizer, local site
management
• WestNilevirus(seeInfectiousDiseases,ID24)
Near Drowning
• mostcommoninchildren<4yrandteenagers
• causeslungdamage,hypoxemia,andmayleadtohypoxicencephalopathy
• mustalsoassessforshock,C-spineinjuries,hypothermia,andscuba-relatedinjuries(barotrauma,air
emboli, lung re-expansion injury)
• complications:volumeshifts,electrolyteabnormalities,hemolysis,rhabdomyolysis,renal,DIC
Physical Exam
• ABCs,vitals:watchcloselyforhypotension
• respiratory:rales(ARDS,pulmonaryedema),decreasedbreathsounds(pneumothorax) • CVS:murmurs,dysrhythmias,JVP(CHF,pneumothorax)
• H&N:assessforC-spineinjuries
• neurological:GCSorAVPU,pupils,focaldeficits
Investigations
• labs:CBC,electrolytes,ABGs,Cr,BUN,INR,PTT,U/A(drugscreen,myoglobin) • imaging:CXR(pulmonaryedema,pneumothorax)±C-spineimaging
• ECG
Management
• ABCs,treatfortrauma,shock,hypothermia • cardiacandO2monitors,IVaccess
• intensiverespiratorycare
■ ventilatorassistanceifdecreasedrespirations,pCO2>50mmHg,orpO2<60mmHgonmaximumO2 ■ may require intubation for airway protection, ventilation, pulmonary toilet
■ high flow O2/CPAP/BiPAP may be adequate but some may need mechanical ventilation with
positive end-expiratory pressure
• dysrhythmias:usuallyrespondtocorrectionsofhypoxemia,hypothermia,andacidosis
• vomiting:verycommon,NGsuctiontoavoidaspiration
• convulsions:usuallyrespondtoO2;ifnot,diazepam5-10mgIVslowly
• bronchospasm: bronchodilators
• bacterialpneumonia:prophylacticantibioticsnotnecessaryunlesscontaminatedwaterorhottub
(Pseudomonas)
• alwaysinitiateCPRindrowning-inducedcardiacarrestevenifpatienthypothermic;continueCPR
until patient is fully rewarmed
Disposition
• non-significantsubmersion:dischargeaftershortobservation
• significant submersion (even if asymptomatic): long period of observation (72 h) as pulmonary edema
may appear late
• CNS symptoms or hypoxemia: admit
• severehypoxemia,decreasedLOC:ICU
“Secondary drowning” where the onset of symptoms, as a result of pulmonary edema or infection, can be insidious, developing over hours, or possibly even days, must be anticipated in the near drowning patient