Environmental

Rapid Review

• Background
  • Dog bites can cause extensive tissue damage and infection with pasteurella, staph, strep, and Capnocytophaga species. 
• Signs/Symptoms
  • Typically have a ragged, torn appearance. 
  • Infected bites may become erythematous, swollen, and tender
• Diagnosis
  • Clinical diagnosis based on history/physical exam
• Treatment
  • Wound irrigation with or without closure.
  • Rabies and tetanus prophylaxis. Consider antibiotics (ex. Augmentin) for high-risk wounds.

Pearls

Deep Dive

• Dog Bite Management: The Evidence (First 10 EM)

Rapid Review

• Background
  • Defined as experiencing respiratory impairment from submersion or immersion in a liquid
  • In addition to hypoxia, may also be associated with hypothermia, fluid aspiration, and spinal injuries
• Signs/Symptoms
  • SOB, respiratory failure, AMS
  • Intercostal retractions, cyanosis 
• Diagnosis
  • Clinical diagnosis
  • Pulse oximetry, ABG, and CXR can help determine severity. Consider CT head/spine if associated with trauma.
• Treatment
  • Resuscitate patients in cardiac arrest with special emphasis on ventilations
  • For non-arrest patients, manage hypoxemia, hypothermia, and associated trauma injuries. Antibiotics for patients who develop aspiration pneumonia.

Pearls

Deep Dive

• Drowning and Submersion Injuries (emDOCs)

Rapid Review

• Background
  • Frostbite is a consequence of prolonged exposure to freezing temperatures, causing freezing and crystallization of fluids in the interstitial and cellular spaces.   
  • Typically occurs on distal extremities and areas of exposed skin
• Signs/Symptoms
  • Affected area will be cold, hard, white, and numb initially
  • After rewarming, the area will be erythematous, swollen, and painful. Full extent of injury may not be evident for several days
• Diagnosis
  • Clinical diagnosis
• Treatment
  • Rewarming in warm water (37 to 40° C). Do not attempt if refreezing is a risk.
  • Provide analgesia, wound care,and prophylaxis against tetanus. Amputation will be considered after demarcation of necrotic tissue occurs (after at least 3 weeks)

Pearls

Deep Dive

• Frostbite (Merck Manual)

Rapid Review

• Background
  • Heat stroke is an abnormal elevation in core body temperature leading to altered mental status and organ dysfunction. It can be either nonexertional (e.g. elderly, drug abuse, prescription medication) or exertional (heavy exercise often in the young, healthy patient).
• Signs/Symptoms
  • CNS dysfunction (confusion, delirium, seizure) is a hallmark sign
  • Temperature > 40° C (104 ° F), tachycardia, tachypnea
• Diagnosis
  • Clinical diagnosis
  • Differentiated from heat exhaustion by presence of CNS dysfunction and temperature > 40° C
• Treatment
  • Aggressive cooling (cold water immersion, evaporative cooling).
  • Manage associated conditions, such as dehydration, rhabdomyolysis, and acute kidney injury

Pearls

Deep Dive

• Heat Stroke (emDOCs)

Rapid Review

• Background
  • Snake envenomation (bite from a poisonous snake) can cause a wide range of symptoms from mild to life-threatening. 
• Signs/Symptoms
  • Crotalid (e.g. Pit Viper) bites cause hemotoxic symptoms, such as bleeding, local swelling and bruising, as well as systemic symptoms, including vomiting, confusion and shock. 
  • Elapid (e.g. coral snake) envenomation can cause neurotoxic symptoms, such as cranial nerve weakness, paresthesias, difficulty swallowing or respiratory depression.
• Diagnosis
  • Clinical diagnosis; based on positive identification of snake and signs/symptoms of envenomation
• Treatment
  • Supportive care (remove jewelry, wrap wound loosely, immobilize at heart level). Antivenom is indicated for any moderate-severe symptoms
  • Manage hypotension, allergic reactions/anaphylaxis, and monitor for compartment syndrome

Pearls

Deep Dive

• Snakebites (Merck Manual)