1. ENVIRONMENTAL DISORDERS BRADEN MCINTOSH

2. OBJECTIVE Burns Freezing injuries Hypothermia Hyperthermia

3. BURNS

4. EPIDEMIOLOGY 500000 burns per year 40000 admissions 4000 deaths

5. PATHOPHYS: DISRUPTION OF CELL MEMBRANES Disrupts sodium pumps Efflux of K Release of histamines, kinins, arachidonic acid, oxygen radicals Increased svr Met acidosis Increased hct Local injury

7. RULE OF 9'S

9. MANAGEMENT Airway- enclosed space Pain control Parkland formula- give lr Watch for rhabdo Local wound care: bacitracin, silvadene, jelly gauze Escharotomy if circumferential

10. DISPO Minor burns- < 15% bsa partial or 2% full - dc Moderate- 15-25% partial and 2-10% full- admit Major- >25% partial or 10% full, hands, face, major joint, feet - burn center

11. COLD INJURIES

13. PATHOPHYS Capillary stasis and thrombosis (hunting response) Ice crystal formation Reperfusion injury- txa, pge, endothelial damage, clumping, sludging, tissue loss

14. TRENCHFOOT Non-freezing injury Prolonged cooling accelerated by wet conditions Nerve damage Numbness. Tingling Tx: supportive- keep feet clean, warm, dry, elevated

15. CHILLBLAINS Non freezing dry injury Erythematous, pruritic and burning paresthesias Tx- supportive: rewarming, loose dressings, topical steroids

16. FROST BITE: PRESENTATIO N Superficial (skin soft) - vesicles> black and hard skin> sloughing Deep (hard)- hemorrhagic vesicles> mummification and sloughing Can't tell degree until reperfusion

17. FROST BITE MANAGEMENT Rapid rewarming circulating water 40-42 deg Tetanus Wound care- debride clear vesicles, leave hemorrhagic ones, dress wounds, aloe Ibuprofen Pen G

18. HYPERTHERMIA

19. PATHOPYHS Normal body regulation fails Excess heat > protein desaturation > cell death and endothelial damage dehydration > cardiovascular and metabolic derangements Heat cramps, exhaustion, stroke

20. HEAT CRAMPS Painful involuntary contractions 2/2 def of sodium and potassium Tx- fluids and salt replacement

21. HEAT EXHAUSTION 2/2 hyponatremia or hypovolemia Presents as ha, n, vom. No cns impairment Temp not > 40 Tx: cool environment and fluids

22. HEAT STROKE Heat exhaustion plus temp > 40 and/ or ams Classic vs. exertional Mortality- 30-80% Tx: cooling- evaporative is best, can do immersion, benzos for inappropriate shivering, avoid pressors Stop once you get to core of 39 Watch for renal failure. Hematologic disorders, respiratory distress and seizures

23. HYPOTHERMIA

24. PREDISPOSIN G FACTORS Drunk Hypoglycemia malnutrition addison's Infection myxedema

25. PATHOPHYS Defined as core temp < 35 Excitation and slowing phases Cardio- inc bp, hr, co > 32 degrees then all downhill, j waves, brady> afib > vfib> asystole Pulm- left shift of oxy hgb curve, abg looks better than it really is GI- pancreatitis and hepatic dysfxn Heme- enzyme malfxn> dic Renal- atn and volume depletion Nervous- cns depression

26. MANAGEMENT: REWARMING passive external- warm env, remove clothes active external- forced air, warming blanket, warm water immersion active internal- heated iv fluids, gastric, peritoneal, bladder lavage, bypass, chest tubes Shock once Don't give insulin Can't pronounce until 35 degrees

27. QUESTION #1 30 y/o m p/w eythematous tingly lesion on tips of toes after dry cold not < freezing. Dx? Frostnip, frost bite, trench foot, chillblains

28. QUESTIONS?

29. BILBOIOGRAPHY Tintinalli, et al. Tintinalli's emergency medicine: a comprehensive study guide. Environmental disorders. Marx, hockberger. Rosen's emergency medicine- concepts and clinical practice. Environmental disorders. Rivers. Preparing for the written board exam in emergency medicine. Environmental disorders. Hippo EM