J CM ER

#1 cause of burns

hot drinks

1st degree burn (superficial thickness) sx*

epidermis only

red burns that BLANCH, NO blisters

erythema, minor pain

tx of 1st degree burn*

aloe

benzocaine

pain = ibuprofen/acetaminophen

2nd degree burn (superficial partial thickness) burn findings*

superficial (papillary) dermis

blisters b/w epidermis and dermis that BLANCH with pressure, looks WET

clear fluid, pain, moist + weep

2nd degree burn (superficial partial thickness) tx*

drain large, floppy blisters

bacitracin/silvadene

sterile vaseline gauze

± topical anesthetic, ibuprofen, acetaminaphen

2nd degree burn (deep partial thickness) findings*

deep (reticular) dermis

easily unroofed blisters that do NOT blanch w pressure, WAXY appearance, DEC pain, hemorrhagic blisters

be concerned with hypothermia, water/electrolyte loss, infx

2nd degree burn (deep partial thickness) tx*

opioids

ibuprofen = anti-inflamm

tetanus prophylaxis

3rd degree burn (full thickness) findings*

dermis/muscle/bone (destroys dermis entirely)

waxy white/leathery gray, insensate**, hard eschar, charring

3rd degree burn (full thickness) tx*

cover w sterile vaseline gauze

skin grafting

biobrane/pig skin

narcotics/ketamine/sedatives/ibuprofen

tetanus prophylaxis

rule of 9’s (adult Lund and Browder chart)*

Head + neck = 9%

Chest + abdomen = 18%

Back + butt = 18%

1 entire arm = 9%

1 entire leg = 18%

special concerns for a burn victim*

1. any burn to face/hands/feet/genitalia/circum burn

2. 3rd degree or full thickness burns that covers large area

3. any burn that interferes w respiration

4. any burn to infant/elderly

5. any chemical/electrical burn (alkali** more caustic > acid)

why is circumferential burn a concern?

the healing process → compartment syndrome/compress on that body part (tourniquet)

sx that a burn is evidence of abuse*

pattern burns that suggest contact w/ object

cigarette burns

stocking/glove/circum burn

burns to genitalia/perineum

major factors involved in severity of electrical burn*

AMOUNT of shocking current through body

DURATION

PATH

immediate death with burns is the result of?*

coexisting trauma

airway compromise

NOT THE BURN ITSELF

remember to remove the person from the source of burn!

signs of inhalation injury*

carbonaceous sputum

singed facial / nasal hairs

facial burns

oropharyngeal edema

changes in voice

altered mental status

initial management of burns

1. ABC

2. stop burn process (remove clothing, cool tissures)

3. irrigate chemical burns for 15 mins

4. circumferential full thickness burns require escharotomy

5. AMPLE = allergies, meds, PMH, last meal, events leading to injury

6. IV access, labs, foley, abx, wound care, pain control

3 RF for death (with burns)*

1. >60 yo

2. more than 40% BSA burned

3. inhalation injury

ARDS

edema from leaky capillaries from traumatized lung

(inhalation injury)

what burn pts hospitalized vs. goes home?

admission:

• full thickness (3rd degree) >5% BSA

• partial thickness (2nd degree) >10% BSA

• any full thickness/partial thickness around critical areas (face, hands, feet, genitals, perineum, skin) → significant risk for fx problems

• circumferential burns (thorax/extremities)

• significant chemical injury, electrical burns, lightning injury, coexisting major trauma, significant comorbidities

• presence of inhalation injury

goes home

• first degree

_ venom is associated with neuromuscular paralysis

elapids

produces complex/mixed toxidromes (muscle/tissue destruction)

neurotoxic snake venoms cause _ paralysis

descending

diplopia, ptosis, dysphagia, dysarthria, muscle weakness,

characteristics of elapid bites

snake hangs on → multiple tiny bite wounds

^ higher risk of envenomation vs. crotalid bites

minimal pain, redness, swelling

systemic effects of elapid envenomation + tx

sx delayed several hours!

euphoria, local paresthesia, N/V, drowsiness, dysphagia

antivenom can PREVENT paralysis but can NOT REVERSE it

→ NO fasciotomy, MUST treat if no snake ID, tourniquets

viperidae is the subfamily of?

crotalidae (pit vipers) = venous members of this family

moveable anterior fangs

viperids venom + systemic effects

cytotoxic and myotoxic effects

possible sig dysregulation of coag

= soft tissue necrosis, rhabdo, DIC

hypotension, fasiculations, diaphoresis, N/V, coag

mixed toxidrome (“broken neck” syndrome)

sx of viperidae envenomation

metallic taste

perioral tingling

fang marks

vesicles, necrosis

local swelling/pain/ecchymosis/erythema

Which snake is responsible for the most fatalities in North America?

Rattlesnake

grading for viperidae (crotalidae) bites

None

Minimal

Moderate

Severe

Moderate + severe might require fasciotomy

non-venomous vs venomous snake bites*

non-venomous: horseshoe

venomous:

• crotalid = fang marks

• elapidae = multiple tiny puncture wounds

why not to apply cold packs to snake bites?*

if you concentrate the venom where the bite is

→ DEC neurotoxic (don’t want to spread) BUT INC cytotoxic (you want cytotoxic venom to spread)

→ more risk of damage to area

what family of deadly snakes do not kill by envenomation?*

boidae (boas, pythons, anacondas)

kills by crushing

prehospital care of snake bite

ID snake

carry victim

remove jewelry

tourniquet (only in elapids)

do NOT “cut and suck”

NO cold packs

what does antivenom have

IgG antibodies

big SE: allergic rxn (Type 1 or 4 d/t the Fc portion/bottom part of “Y”)

mechanisms of type 1 hypersensitivity reactions*

1. must have previous sensitization to antigen against IgE (which is made by antibody-producing B lymphocytes)

2. release of chemical mediators from mast cells, basophils, eosinophils

3. histamine release → inc capillary permeability and vasodilation

what 2 WBC are bound to IgE → anaphylaxis?

eosinophils → degranulate

basophils → degranulate

neutrophils (eventually)

mast cell definition

basophils hat have migrated to a tissue

monocyte that has gone into tissues

macrophage

causes of anaphylaxis

1. proteins (food, venom, insulin)

2. haptens (PCN, abx, some anesthetics)

3. prostaglandin inhibitors (ASA, NSAID)

4. physical factors (exercise, stress, cold)

5. anaphylactoid (mast cell degranulation NOT from IgE ie vit K, morphine)

premonitory symptoms of anaphylaxis*

#1: pruritis of palms/soles

tingling in mouth/tongue

tightness in chest

dizziness/syncope

palpitations

clinical presentation of anaphylaxis*

urticaria (edema upper dermis, generalized flushing, wheals)

angioedema (PAINLESS edema of deep dermis d/t to vasodilation and 3rd spacing, “puffy” near mucous membranes)

laryngeal edema (“lump in throat”/hoarseness)

angioedema in uvula (pt chokes when speaking)

steeple sign

→ hypotension, CV collapse, respiratory arrest, GI

part of skin with most capillaries

deep dermis layer

treatment of anaphylaxis*

1. airway compromise → epi 0.3cc SQ

2. IV, O2, monitor, hydrate

3. hypotension/airway obstruction → epi 1.0cc IV

4. prepare intubate → cricothyrotomy tray

5. mild bronchospasm → inhaled beta-agonists (albuterol)

6. antihistamines

7. solumedrol or hydrocortisone IVP (q4hr)

8. terbutaline

9. if on BB, give glucagon

frostnip definition (mild)

superficial reversible ice crystal formation

frostnip information*

mild + least serious form of hypothermia

warm skin, sensate, normal texture

PE exam of frostnip*

painful sensations

darker areas of skin

red hyperemic skin

definition of chilblains (pernio) - moderate

painful inflammation of SMALL blood vessels in skin

occurs in response to sudden warming from cold temperatures

clears up within 1-3 weeks

chilblains (pernio) PE

red patches

blisters and swelling on extremities

frostbite (severe) definition

destruction of tissues d/t freezing

superficial damage can be reversed w tx

if severe (injury to reticular dermis + subdermal plexus → bone, muscle, tendon) → mummification

factors determining tissue loss from frostbite

magnitude of temperature depression

length of exposure

wetness/immersion

wind

associated factors of frostbite

1. poor nutrition

2. smoking/etoh

3. vascular disease

4. immunocompromised

PE findings of different severities of frostbite*

superficial: numb, white/yellow/molted, aching, throbbing/firm

moderate: vesicles/bullae w clear fluid

severe: gangrene, bullae w purple bloody fluid, waxy hard skin (deep injury)

prehospital management of frostbite*

do NOT rub/aggressively manipulative frozen parts

do NOT warm pre-hospital

remove cold clothing

trim clothing frozen to skin

treat systemic hypothermia

consider corneal/internal/bony injury

hospital management of frostbite*

tetanus shot

rapid thawing (40-42 C) ASAP!!

dress fingers and toes individually

leave hemorrhagic blisters intact

analgesia

elevate, split, avoid pressure

how is immersion foot similar/diff from frostbite?*

1. devs slowly and has no actual freezing

2. no ice crystals

3. neurovasc dmg/hypersensitivity/paresthesia/gangrene

4. immediate appearance = red

5. later = pale, edema, numb, pain

6. better prognosis than frostbite

systemic hypothermia is when the core temp is less than _*

35 C (95F)

organ dysfx occurs once temp goes below 35c

systemic hypothermia mild, mod, severe*

mild (32-35C): elevated HR and resp rate, alt mental status, shivering

mod (28-32C): shivering stops, worse vitals, stupor, polyuria, wheezing, a fib, osborn waves

severe (<28C): v fib occurs <28C, mydriasis (dilated pupil), coma, weak pulse, slow respiration, no reflex, bradycardia, heart block, v fib, asystole

RF/predisposing factors to systemic hypothermia

dec heat prod (CNS depression, immobility, endocrine failure, hypoglycemia)

inc heat loss (exposure, drugs, sepsis, neuro)

hypothalmic dysfx (acidosis, anoxia, stroke)

iatrogenic cooling (or, surgery)

how to warm a hypothermic patient?*

1. cardiac bypass (9-18C/hr)

2. chest tubes (3-6C/hr) - thoracic lavage

3. peritoneal lavage (3)

4. bladder irrigation w foley catheter (2)

5. shivering (1.5C)

6. warming blanket (2)

7. warm O2 w ET tube (1.5)

8. wram O2 w mask (1)

9. warm IV fluids (NO lactate) - least effective

10. bretylium - most effective

11. open cardiac massage

1st line tx for hypothermia*

bretylium

when can you declare death of hypothermic pt?*

the pt isn’t dead until he’s warm and dead

30-32C+ to be pronounced dead

if K+>10 = pt is not coming back even if cold and dead

what to be aware of when actively rewarming someone after hypothermia?*

afterdrop

second drop in temp d/t reperfusion of cold extremities

how are toxins classified?

• meds

• illicit substances

• heavy metals

• marine foodborne illness

• plant/mushroom toxins

what are the pertinent historical considerations when a person is poisoned?

• exposure

• when and why

• what form is toxin

• route of exposure

• how much/long was exposure

body systems in person who is poisoned*

blood pressure

heart rate

respiratory rate

body temp

pupillary diameter

nyastagmus

poisoned drugs that cause hypertension

amphetamines,

cocaine,

ergot,

head trauma,

MAOI,

PCP

poisoned drugs causing hypotension

BB,

amantia mushrooms,

CCB,

opioids,

TCA< phenothiazines,

sedatives

poisoned drugs causing tachycardia

amphetamines,

antichol,

ethanol,

nicotine,

organophosphates,

PCP

poisoned drugs causing bradycardia

BB,

cholinergic,

CCB,

clonidine,

digoxin,

opioids,

sedatives

poisoned drugs causing hyperventilation

ASA,

sympathomimetics,

hydrocarbons,

alc,

withdraw

poisoned drugs causing hypoventilation

botulin toxin,

ethanol,

organophosphates,

sedative,opioids

poisoned drugs causing hyperthermia

amphetamines,

anticholinergics,

cocaine,

phencyclidine,

ASA,

phenothiazines,

EtOH/Sedative withdrawal,

thyroid storm

poisoned dugs causing hypothermia

ethanol,

opioids,

phenothiazines,

sedative-hypnotics

, hypoglycemia

poisoned drugs causing miosis

cholinergics,

opioids,

PCP,

sedative-hypnotics,

phenothiazines

poisoned drugs causing mydriasis

anoxia,

anticholinergics,

sympathomimetics

poisoned drugs causing nystagmus

ethanol

pcp

phenytoin

sedatives

Amphetamines toxidromes

Hyperthermia

Tachycardia

Hypertension

anticholinergics toxidromes

Hyperthermia

Tachycardia

Mydriasis

Cocaine toxidromes

Hyperthermia

Hypertension

Phencyclidine (PCP) toxidromes

Hyperthermia

Tachycardia

Hypertension

Miosis

Nystagmus

MAOI toxidrome

hypertension

ASA toxidromes

Hyperthermia

Tachycardia

Hyperventilation

phenothaizines toxidrome

Hyperthermia

Tachycardia

Hypotension

Miosis

opioids toxidrome

Hypothermia

Bradycardia

Hypotension

Hypoventilation

Miosis

et/oh sedative withdrawal toxidrome

Hyperthermia

Hyperventilation

thyroid storm toxidrome

hyperthermia

nicotine toxidrome

tachycardia

organophosphates toxidromes

tachycardia

hypoventilation

treatment for poisoned pt*

1. labs (CUTE DIMPLES, glucose, BMP, HCG, utox, etoh, acetaminophen/ASA, EKG)

2. charcoal

3. gastric lavage

4. acute stabilization + antidote

cholinergic toxidrome (SLUDGE syndrome)*

1. salivation

2. lacrimation

3. urination

4. diaphoresis

5. GI upset

6. emesis

antidote for opioid (heroin, morphine, oxycodone)

narcan

antidote for acidosis, cocaine, cyanide, salicylate, TCA, barbiturate, cardiac arrest

bicarb

antidote for digoxin

digibind

antidote for cholinergic, organophosphates, cholinesterase, neuromuscular blockade

atropine

antidote for organophosphate + cholinesterase

pralidoxime

antidote for toxic alcohol poisoning (methanol/ethylene glycol)

ethanol

antidote for beta blocker, insulin, CCB, hypoglycemia, anaphylaxis

glucagon

antidote for acetaminophen

N-AC ((N-acetyl cysteine)

antidote for benzo, reversal for sedation + respiratory depression

flumazenil

most feared complication of methanol poisoning

blindness