environmental exposures

Environmental Environmental exposuresexposures

Nikki Waller, MDNikki Waller, MDMedical Student ClerkshipMedical Student Clerkship

2009-20102009-2010

Self-Directed Learning AssessmentsSelf-Directed Learning Assessments

SnakesSnakes

8,000 venomous snake bites/yr in US8,000 venomous snake bites/yr in US ~10 deaths/yr~10 deaths/yr 25% bites are dry bites25% bites are dry bites Venomous:Venomous:

1.1. Imported snakesImported snakes2.2. Coral SnakesCoral Snakes3.3. Crotaline Snakes/Pit VipersCrotaline Snakes/Pit Vipers

RattlesnakesRattlesnakesCopperheadCopperheadWater MoccasinWater MoccasinMassasaugaMassasauga

www.zanesville.ohiou.edu

Clinical EffectsClinical Effects

www.rk19-bielefeld-mitte.de

Coral SnakeCoral Snake

Brightly ColoredBrightly Colored Black-Red-Yellow Black-Red-Yellow

patternpattern RED touches YELLOW RED touches YELLOW

= kill a fellow = kill a fellow vs vs

Red on Black = Red on Black = venom lackvenom lack

ONLY Eastern Coral ONLY Eastern Coral Snake bite requires Snake bite requires treatment treatment

www.zanesville.ohiou.edu


Eastern Coral Snake venom is potent Eastern Coral Snake venom is potent neurotoxinneurotoxin

Symptoms:Symptoms:• TremorTremor• SalivationSalivation• Respiratory paralysisRespiratory paralysis• SeizuresSeizures• Bulbar palsies( dysarthria, diplopia, Bulbar palsies( dysarthria, diplopia,

dysphsgia)dysphsgia)


Admit for 24-48 hours observationAdmit for 24-48 hours observation ALL patients with POTENTIAL ALL patients with POTENTIAL

envenomation – 3 vials of antivenimenvenomation – 3 vials of antivenim Antivenim (Antivenim (M fulviusM fulvius))

• At least 3 vialsAt least 3 vials• If sxs – additional dosesIf sxs – additional doses

Symptomatic Pts are admitted to ICUSymptomatic Pts are admitted to ICU

Arizona Coral Snake Arizona Coral Snake

Sonoran(Arizona) Sonoran(Arizona) Coral Snake bite Coral Snake bite does not require does not require treatmenttreatment

Few symptomsFew symptoms

Local wound care Local wound care only only

www.pitt.edu

Coral Snake MimicCoral Snake Mimic

Red and yellow, kill Red and yellow, kill a fellow; red and a fellow; red and black, friend of black, friend of Jack." Jack."

www.stetson.edu

jungledomain.org

Coral Snakes in the US Coral Snakes in the US

www.backyardnature.net/ snakvenm.htm

Crotalinae (Pit Vipers) BitesCrotalinae (Pit Vipers) Bites Identified byIdentified by

• 2 retractable fangs2 retractable fangs• Heat sensitive Heat sensitive

depressions (pits) depressions (pits) located between each located between each eye & nostril eye & nostril

Clinical Effects depend on:Clinical Effects depend on:• Size & species of snakeSize & species of snake• Age & size of victimAge & size of victim• Time since biteTime since bite• Characteristics of bite Characteristics of bite

Crotalinae (Pit Vipers) BitesCrotalinae (Pit Vipers) Bites Hallmark of bite – fang marks Hallmark of bite – fang marks

with local pain & swellingwith local pain & swelling Severity classification:Severity classification:

• Degree of local injuryDegree of local injury Swelling, pain, ecchymosis Swelling, pain, ecchymosis

• Degree of systemic Degree of systemic toxicity toxicity

Hypotension, Hypotension, tacchycardia, paresthesiastacchycardia, paresthesias

• Evolving coagulopathyEvolving coagulopathy Thrombocytopenia, Thrombocytopenia,

elevated PT, elevated PT, hypofibrinogenemiahypofibrinogenemia

Crotalinae (Pit Vipers) BitesCrotalinae (Pit Vipers) Bites Any 1 of the 3 classes = envenomationAny 1 of the 3 classes = envenomation No sxs at 8-12 hours = no bite or dry biteNo sxs at 8-12 hours = no bite or dry bite All envenomations have swelling at 30 minutes All envenomations have swelling at 30 minutes

• Rarely onset up to 12 hoursRarely onset up to 12 hours Degree of envenomationDegree of envenomation

• Minimal: local sxs onlyMinimal: local sxs only• Moderate: systemic sxs and coagulation parameter Moderate: systemic sxs and coagulation parameter

abnormalitiesabnormalities• Severe: extensive swelling, potentially life threatening Severe: extensive swelling, potentially life threatening

systemic signs, markedly abnormal coagulation systemic signs, markedly abnormal coagulation parameters that may result in bleedingparameters that may result in bleeding

Crotalinae (Pit Vipers) BitesCrotalinae (Pit Vipers) Bites

Diagnostic tests: CBC, Coags, Type & Diagnostic tests: CBC, Coags, Type & Screen Screen

Treatment:Treatment: • Resources: Arizona Poison Control 520-Resources: Arizona Poison Control 520-

626-6016626-6016• Prehospital:Prehospital:

Minimize physical activity & remain calmMinimize physical activity & remain calm Immobilize bite site & place in neutral Immobilize bite site & place in neutral

position below heart position below heart


Treatment (continued):Treatment (continued): Cardiac monitor, IV’s, resuscitate based on Cardiac monitor, IV’s, resuscitate based on

ACLSACLS Local wound careLocal wound care

• Remove FBRemove FB• Td BoosterTd Booster

Measure & Record limb circumference at Measure & Record limb circumference at several sites above and below site of bite, several sites above and below site of bite, repeat q 30 minutesrepeat q 30 minutes

Mark border of advancing edema q 30minMark border of advancing edema q 30min

CroFabCroFab Polyvalent Crotalidae Immune Fab(CROFAB)Polyvalent Crotalidae Immune Fab(CROFAB)

• Any pt with progressive swelling, systemic sxs or Any pt with progressive swelling, systemic sxs or coagulopathy coagulopathy

• Sheep derived antivenimSheep derived antivenim• Replaced Antivenin (Crotalidae) Polyvalent( equine Replaced Antivenin (Crotalidae) Polyvalent( equine

derived)derived)• Initial Dose: 4-6 vials IVInitial Dose: 4-6 vials IV• Diluted in 250ml H20 & infused over 60 minsDiluted in 250ml H20 & infused over 60 mins• Dosing same for children, amount of diluent is adjustedDosing same for children, amount of diluent is adjusted• @1HR, if any of 3 parameters have not halted, repeat @1HR, if any of 3 parameters have not halted, repeat

dose of 4-6 vials givendose of 4-6 vials given• Labs checked q4 h or after each round of CrofabLabs checked q4 h or after each round of Crofab• End point is arrest of sxs and coagulopathy, IF NOT KEEP End point is arrest of sxs and coagulopathy, IF NOT KEEP

TREATINGTREATING• After control of sxs, Protocol After control of sxs, Protocol

CroFabCroFab

• @1HR, if any of 3 parameters have not @1HR, if any of 3 parameters have not halted, repeat dose of 4-6 vials givenhalted, repeat dose of 4-6 vials given

• Labs checked q4 h or after each round Labs checked q4 h or after each round of Crofabof Crofab

• End point is arrest of sxs & End point is arrest of sxs & coagulopathy, IF NOT KEEP TREATINGcoagulopathy, IF NOT KEEP TREATING

• After control of sxs, Protocol as follows:After control of sxs, Protocol as follows: 2 vials q 6h for additional 18 hours ( 3 more 2 vials q 6h for additional 18 hours ( 3 more

doses)doses)

CroFabCroFab The cost of CroFab is $ 750 The cost of CroFab is $ 750

per vialper vial Total Total costcost of therapy for a of therapy for a

snakebite ranges from snakebite ranges from $10500 (4-4-2-2-2 vials) to $10500 (4-4-2-2-2 vials) to $13500 (6-6-2-2-2 vials) $13500 (6-6-2-2-2 vials)

Average treatment Cost: Average treatment Cost: $10,000 per patient$10,000 per patient

Estimated 8,000 venomous Estimated 8,000 venomous snakebites in the US each snakebites in the US each yearyear

Market potential of up to Market potential of up to US$80 million/yrUS$80 million/yr

protherics.matinee.co.uk/ products/Critical_Care_Products.asp

Compartment SyndromeCompartment Syndrome

Pressure > 30 : limb elevation & Pressure > 30 : limb elevation & repeat CroFab dosingrepeat CroFab dosing

Persistently elevated PressurePersistently elevated Pressure• Mannitol 1-2 g/Kg IV over 30 minutesMannitol 1-2 g/Kg IV over 30 minutes• Surgical Consult for FasciotomySurgical Consult for Fasciotomy


DISPOSITIONDISPOSITION• Observe for at least 8 hoursObserve for at least 8 hours• Severe bites and anyone receiving Severe bites and anyone receiving

continued antivenin -> ICU continued antivenin -> ICU • Must warn patients about Serum Must warn patients about Serum

Sickness with CrofabSickness with Crofab 16% patients16% patients 7-14 days after therapy7-14 days after therapy Tx with Prednisone 60mg/d PO tapered over Tx with Prednisone 60mg/d PO tapered over

1-2 weeks 1-2 weeks

Pit Vipers in the US Pit Vipers in the US

Western Diamondback Western Diamondback Rattlesnake Habitat Rattlesnake Habitat

Eastern Diamondback Eastern Diamondback Rattlesnake Habitat Rattlesnake Habitat

Gila Monster Bite Gila Monster Bite Tenacious biteTenacious bite Often lizard still attachedOften lizard still attached To remove: To remove:

• Place lizard on solid Place lizard on solid surfacesurface

• Submersion in waterSubmersion in water• Cast SpreaderCast Spreader• Local irritating flameLocal irritating flame

Local wound careLocal wound care Search for teethSearch for teeth No further treatment No further treatment

required required

www.californiaherps.com

www.mendosa.com

Gila Monster BiteGila Monster Bite

Symptoms: Pain & Symptoms: Pain & swellingswelling

Rare systemic Rare systemic toxicitytoxicity

Systemic SXS:Systemic SXS:• DiaphoresisDiaphoresis• ParesthesiaParesthesia• WeaknessWeakness• HTNHTN

www.aintitcool.com

Gila Monster HabitatGila Monster Habitat

www.pueblozoo.org

Hypothermia: Epidemiology Hypothermia: Epidemiology Defined as a core temperature < 35°C (95°F)Defined as a core temperature < 35°C (95°F) US Deaths:700 per yr US Deaths:700 per yr

• Half > 65 yoHalf > 65 yo At Risk: Age Extremes & Altered sensoriumAt Risk: Age Extremes & Altered sensorium ““Causes of Hypothermia: Clinical SettingsCauses of Hypothermia: Clinical Settings

• ““Accidental” (environmental)Accidental” (environmental)• MetabolicMetabolic• Hypothalamic and CNS dysfunctionHypothalamic and CNS dysfunction• Drug-inducedDrug-induced• SepsisSepsis• Dermal diseaseDermal disease• Acute incapacitating illnessAcute incapacitating illness• Iatrogenic (fluid resuscitation)Iatrogenic (fluid resuscitation)

HypothermiaHypothermia ETIOLOGIES:ETIOLOGIES: Metabolic causes Metabolic causes

• Hypothyroidism, hypoadrenalism, hypopituitarismHypothyroidism, hypoadrenalism, hypopituitarism• Each lead to a decrease in metabolic rateEach lead to a decrease in metabolic rate• Hypoglycemia also may lead to hypothermia Hypoglycemia also may lead to hypothermia

CNS dysfunction CNS dysfunction

• Head trauma, tumor, strokeHead trauma, tumor, stroke• Wernicke diseaseWernicke disease

Potentially reversible with thiamine Potentially reversible with thiamine

Alcohol & DrugsAlcohol & Drugs• In the US, most hypothermic patients are intoxicated In the US, most hypothermic patients are intoxicated • Ethanol Ethanol

Vasodilator & anesthetic and CNS depressant effectsVasodilator & anesthetic and CNS depressant effects Don’t Feel the Cold and Don’t respond to it Don’t Feel the Cold and Don’t respond to it

HypothermiaHypothermia ETIOLOGIES:ETIOLOGIES: SepsisSepsis

• Poor prognostic factor in patients with bacteremiaPoor prognostic factor in patients with bacteremia

Severe infections, DKA, immobilizing injuries, and Severe infections, DKA, immobilizing injuries, and

various other conditions impair thermoregulatory various other conditions impair thermoregulatory functionfunction

Trauma patientsTrauma patients• Resuscitation with room-temperature fluid & cold bloodResuscitation with room-temperature fluid & cold blood• At risk: Pts undergoing massive volume replacementAt risk: Pts undergoing massive volume replacement

Hypothermia: Physiology Hypothermia: Physiology 32° to 35°C (89.6°–95°F) = “mild” hypothermia32° to 35°C (89.6°–95°F) = “mild” hypothermia Excitation (responsive) stage Excitation (responsive) stage Body attempts to retain & generate heatBody attempts to retain & generate heat HR, CO & BP all riseHR, CO & BP all rise

Below 32°C (89.6°F) = moderate hypothermiaBelow 32°C (89.6°F) = moderate hypothermia Slowing (adynamic) stageSlowing (adynamic) stage Progressive slowdown of bodily functions & Progressive slowdown of bodily functions &

metabolism metabolism Decrease O2 utilization & CO2 productionDecrease O2 utilization & CO2 production Below 30° to 32°C (86°–89.6°F) - shivering stops Below 30° to 32°C (86°–89.6°F) - shivering stops

Hypothermia: CardiacHypothermia: Cardiac Dysrhythmias at Temp < 30°C (86°F)Dysrhythmias at Temp < 30°C (86°F)

Typical sequence:Typical sequence: Sinus Brady -> slow AFIB -> VFIB -> asystoleSinus Brady -> slow AFIB -> VFIB -> asystole

Myocardium - extremely irritableMyocardium - extremely irritable• VFIB induced by rough handling of patientVFIB induced by rough handling of patient

Dysrhythmias:Dysrhythmias: Sinus bradycardia Sinus bradycardia AFIB or flutter AFIB or flutter Nodal rhythms Nodal rhythms AV block AV block PVCs PVCs Ventricular fibrillation Ventricular fibrillation Asystole Asystole

HypothermiaHypothermia

ECG Changes in Hypothermia:ECG Changes in Hypothermia:T-wave inversionsT-wave inversionsPR, QRS, QT prolongationPR, QRS, QT prolongationMuscle tremor artifactMuscle tremor artifactOsborn (J) waveOsborn (J) wave

Osborn (J) wave:Osborn (J) wave: • Slow, positive deflection at the end of Slow, positive deflection at the end of

the QRS complexthe QRS complex• Characteristic, not pathognomonicCharacteristic, not pathognomonic

Osborn Wave Osborn Wave


Pulmonary:Pulmonary:• Initial tachypnea -> decrease RR & TVInitial tachypnea -> decrease RR & TV• Aspiration pneumonia risk - Bronchorrhea & depressed Aspiration pneumonia risk - Bronchorrhea & depressed

gag reflexgag reflex• ABG: false high PO2 and PCO2 & lower pH ABG: false high PO2 and PCO2 & lower pH • Leftward shift of OxyHgb dissociation curve Leftward shift of OxyHgb dissociation curve

thus impairing O2 releasethus impairing O2 release

CNS:CNS:

• Depression of consciousness Depression of consciousness • SXS: Mild incoordination then confusion, lethargy & SXS: Mild incoordination then confusion, lethargy &

comacoma• Pupils may be dilated & non reactivePupils may be dilated & non reactive


RenalRenal • Cold diuresis c resultant volume lossesCold diuresis c resultant volume losses• Prone to rhabdomyolysis Prone to rhabdomyolysis • Prone to ARF from myoglobinuria & Prone to ARF from myoglobinuria &

hypoperfusionhypoperfusion

HematologyHematology• Prone to intravascular thrombosis and Prone to intravascular thrombosis and

subsequent embolic complicationssubsequent embolic complications• Prone to DIC Prone to DIC • Prone to bleedingProne to bleeding

Hypothermia: DiagnosisHypothermia: Diagnosis

Rectal Temp Rectal Temp Some standard clinical thermometers Some standard clinical thermometers

record only to 34.4°C (94°F)record only to 34.4°C (94°F) Electronic thermometers with flexible Electronic thermometers with flexible

probes can continuously monitor probes can continuously monitor rectal, bladder or esophageal Temprectal, bladder or esophageal Temp

Hypothermia:Treatment Hypothermia:Treatment

ABCsABCs Cardiac Monitor, pulse OxCardiac Monitor, pulse Ox Continuous or repeated Temperature Continuous or repeated Temperature

recordingsrecordings Drugs:Drugs:

• IV thiamine 50 mgIV thiamine 50 mg• If FSBS low: 50 to 100 mL of D50If FSBS low: 50 to 100 mL of D50

Hypothermia:TreatmentHypothermia:Treatment

Rewarming: Active & PassiveRewarming: Active & Passive• Stable cardiac rhythm & Vitals: Stable cardiac rhythm & Vitals:

Passive rewarmingPassive rewarming Noninvasive Active rewarming:Noninvasive Active rewarming:

• Forced-air rewarming, warm O2 & warm IVFForced-air rewarming, warm O2 & warm IVF

• Less than 30° (86°F) Less than 30° (86°F) Rapid rewarming until the temp is 30° to Rapid rewarming until the temp is 30° to

32°C (86°–89.6°F) 32°C (86°–89.6°F) • Minimize dysrhythmiasMinimize dysrhythmias


Passive rewarming:Passive rewarming: 1. Removal from cold environment 1. Removal from cold environment 2. Insulation 2. Insulation

Active external rewarming:Active external rewarming: Warm water immersion Warm water immersion Heating blankets set at 40°C Heating blankets set at 40°C Radiant heat Radiant heat Forced air ( BEAR Hugger) Forced air ( BEAR Hugger)

Hypothermia:TreatmentHypothermia:Treatment Active core rewarming at 40°C:Active core rewarming at 40°C:

• Inhalation rewarming Inhalation rewarming • Warmed, humidified air by face mask or ETTWarmed, humidified air by face mask or ETT

• Heated IV fluidsHeated IV fluids• Warmed to 40°C (104°F)Warmed to 40°C (104°F)

• GI tract lavageGI tract lavage• Pulmonary aspiration if unprotected airwayPulmonary aspiration if unprotected airway

• Bladder lavageBladder lavage• Peritoneal lavagePeritoneal lavage

• Potassium-free dialysis solution at 104°–113°FPotassium-free dialysis solution at 104°–113°F• 2 catheters (instillation & removal)2 catheters (instillation & removal)


Active core rewarming at 40°C:Active core rewarming at 40°C:• Pleural lavagePleural lavage

L thoracic cavity - heated fluid in proximity to the L thoracic cavity - heated fluid in proximity to the heart heart

2 tubes – Instillation and removal2 tubes – Instillation and removal

• Extracorporeal rewarmingExtracorporeal rewarming Pump-assisted cardiopulmonary bypass via femoral Pump-assisted cardiopulmonary bypass via femoral

vessels is the most common vessels is the most common Right atrial–aortic bypass using a median sternotomy Right atrial–aortic bypass using a median sternotomy

and heated hemodialysisand heated hemodialysis

• Mediastinal lavage via thoracotomy Mediastinal lavage via thoracotomy

Local Cold Induced Injury Local Cold Induced Injury

FrostnipFrostnip: less severe than frostbite, no : less severe than frostbite, no tissue loss, resolves with rewarmingtissue loss, resolves with rewarming

Trench footTrench foot: cooling of tissue in a wet : cooling of tissue in a wet environment at above freezing temp over environment at above freezing temp over hrs to dayshrs to days

Chilblains(pernio)Chilblains(pernio): painful & inflamed : painful & inflamed lesions from chronic & intermittent lesions from chronic & intermittent exposure to damp non-freezing ambient exposure to damp non-freezing ambient temp temp

Local Cold Induced InjuryLocal Cold Induced Injury First Degree FrostbiteFirst Degree Frostbite: superficial injury; : superficial injury;

edema, burning & erythema edema, burning & erythema Second Degree FrostbiteSecond Degree Frostbite: above + : above +

blisteringblistering Third Degree FrostbiteThird Degree Frostbite: involves full : involves full

thickness skin & subdermal tissuethickness skin & subdermal tissue Fourth Degree FrostbiteFourth Degree Frostbite: involves above + : involves above +

subcutaneous tissue, muscle, tendon & subcutaneous tissue, muscle, tendon & bone bone • Cyanotic & insensate tissue, hemorrhagic Cyanotic & insensate tissue, hemorrhagic

blisters & skin necrosis blisters & skin necrosis • Later becomes mummified Later becomes mummified

Local Cold Induced InjuryLocal Cold Induced Injury

Treatment:Treatment:• Chilblains & Trench footChilblains & Trench foot: elevate, warm, : elevate, warm,

bandagebandage Rx: Nifedipine 20mg PO TID, Topical steroids, Rx: Nifedipine 20mg PO TID, Topical steroids,

prednisone, prostaglandin E1prednisone, prostaglandin E1

• FrostbiteFrostbite: rapid rewarm with water at 42: rapid rewarm with water at 42oo C C (107(107oo F) for 10-30 minutes F) for 10-30 minutes

Rx: Narcs, ibuprofen, aloe vera, PCN G 500,000 u Rx: Narcs, ibuprofen, aloe vera, PCN G 500,000 u PO q6 for 2-3 daysPO q6 for 2-3 days Debride clear blisterDebride clear blister Don’t puncture Hemorrhagic blistersDon’t puncture Hemorrhagic blisters NO DRY AIR REWARMINGNO DRY AIR REWARMING

Heat Emergencies Heat Emergencies

Heat Exhaustion:Heat Exhaustion:• Sxs: malaise, fatigue, weakness, dizziness, Sxs: malaise, fatigue, weakness, dizziness,

syncope, HA, nausea, vomiting, myalgias, syncope, HA, nausea, vomiting, myalgias, diaphoresis, tachypnea, tachycardia, diaphoresis, tachypnea, tachycardia, orthostatic hypotensionorthostatic hypotension

• Temp: elevated to normalTemp: elevated to normal• Sensorium and Neuro Exam: NORMAL Sensorium and Neuro Exam: NORMAL • Dx Work-up: Check CK to r/o RhabdoDx Work-up: Check CK to r/o Rhabdo• TX: rest, evaporative cooling, IV fluidsTX: rest, evaporative cooling, IV fluids• Dispo: D/C except Electrolyte abnormalities or Dispo: D/C except Electrolyte abnormalities or

Co-morbiditiesCo-morbidities

Heat EmergenciesHeat Emergencies Heat SyncopeHeat Syncope: :

• Cause: volume depletion, peripheral vasodilation, Cause: volume depletion, peripheral vasodilation, decreased vasomotor tonedecreased vasomotor tone

• R/O other causes of syncopeR/O other causes of syncope Heat CrampsHeat Cramps: :

• Painful muscle spasms of calves, thighs, shouldersPainful muscle spasms of calves, thighs, shoulders• Cause: dilutional hyponatremia from replacement with Cause: dilutional hyponatremia from replacement with

free waterfree water Heat tetanyHeat tetany::

• Paresthesias of extremities & circumoral areaParesthesias of extremities & circumoral area• Carpopedal spasms Carpopedal spasms • Cause: respiratory alkalosis from hyperventilation Cause: respiratory alkalosis from hyperventilation

Heat Emergencies: Heat StrokeHeat Emergencies: Heat Stroke Difference from Heat exhaustion is Altered Mental Difference from Heat exhaustion is Altered Mental

Status & Definite elevated Temp Status & Definite elevated Temp Core Temp 40 - 47Core Temp 40 - 47oo C C Neurologic SxsNeurologic Sxs: ataxia, confusion, bizarre : ataxia, confusion, bizarre

behavior, agitation, Szs, obtundation & Coma behavior, agitation, Szs, obtundation & Coma Risk FactorsRisk Factors: Age <4 or > 75yo; CHF, psych : Age <4 or > 75yo; CHF, psych

illnesses, ETOH, dehydration, poverty, social illnesses, ETOH, dehydration, poverty, social isolation, poor conditioning, no access to air isolation, poor conditioning, no access to air conditioning, poorly acclimated to warm weather, conditioning, poorly acclimated to warm weather, medications (B-Blockers, Ca Channel Blockers, medications (B-Blockers, Ca Channel Blockers, Anti-cholinergics) Anti-cholinergics)

Heat Emergencies: Heat StrokeHeat Emergencies: Heat Stroke

Diagnostic Work-upDiagnostic Work-up: CBC, Electrolytes, CK, : CBC, Electrolytes, CK, LFTs, ETOH level, Tox Screen, Coags, UA, LFTs, ETOH level, Tox Screen, Coags, UA, urine myoglobin, U preg, ABG, CXR, EKGurine myoglobin, U preg, ABG, CXR, EKG

Differential DiagnosisDifferential Diagnosis: sepsis, meningitis, : sepsis, meningitis, encephalitis, toxidromes (anticholinergic, encephalitis, toxidromes (anticholinergic, PCP, salicylates, sympathomimetics), DKA, PCP, salicylates, sympathomimetics), DKA, thyrotoxicosis, status epilepticus, stroke, thyrotoxicosis, status epilepticus, stroke, neuroleptic malignant syndrome, neuroleptic malignant syndrome, malignant hyperthermia malignant hyperthermia


Treatment:Treatment: ABCsABCs ETT if altered mental status, hypoxia or ETT if altered mental status, hypoxia or

diminished gag reflexdiminished gag reflex Volume Replacement: dehydrated & Volume Replacement: dehydrated &

prevent Rhabdomyolysisprevent Rhabdomyolysis Evaporative Cooling: disrobe pt; spray Evaporative Cooling: disrobe pt; spray tepidtepid

water at patient via surrounding fans water at patient via surrounding fans Treat shivering with BenzodiazepinesTreat shivering with Benzodiazepines


Aggressive CoolingAggressive Cooling: immersion cooling, : immersion cooling, cold water gastric & urinary bladder cold water gastric & urinary bladder lavage, thoracostomy lavage, lavage, thoracostomy lavage, cariopulmonary bypasscariopulmonary bypass

SeizuresSeizures: treat with Benzos: treat with Benzos RhabdomyolysisRhabdomyolysis::

• IV hydration, furosemide 40mg IV, Na BicarbIV hydration, furosemide 40mg IV, Na Bicarb HyperkalemiaHyperkalemia: normal protocol: normal protocol Admission: ICUAdmission: ICU

environmental exposures

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