EM 1 Study Guide PDF

EM First Exam Content An Introduction to Emergency Medicine **Objectives** Qualities of a Good EM Provider (**team player, patient advocate, high quality care**) Providers Tasks in the ED **(lumbar puncture, cast and splint applic\`ation, Thoracentesis)** **Recognize differences in the Emergenc...

EM First Exam Content An Introduction to Emergency Medicine **Objectives** Qualities of a Good EM Provider (**team player, patient advocate, high quality care**) Providers Tasks in the ED **(lumbar puncture, cast and splint applic\`ation, Thoracentesis)** **Recognize differences in the Emergency Medicine encounter.** - The EM mindset should start with ABC's - A is for **awareness** or situational. Is the patient sick or not? (General Survey - B is for **Basic Life**. (is there a problem with functionality in basic life, organ, and limbs supportive measures) - C is for **controlling imminent threats**, ruling out the worse case scenario in patients who have the potential to self **Describe the approaches to patient triage.** - Patient Acuity (Critical, Emergent, Non-urgent) **[Critical ]** Patient has life or limb threatening emergency and has a high probability of death if immediate intervention is not begun. **[Emergent]** Patients have symptoms of injury or illness that will likely progress in severity if treatment is not quickly begun **[Non-urgent]** Patients have symptoms with low probability of progression to a more serious condition. **How Does Triage Work?** - A patient centered process with prioritization of patient safety. Equitable care and efficiency - Based on the acuity of the patient and the resources needed to treat the patient. (diagnostics, therapeutic interventions such as labs, imaging, IV management) - Improves patient flow and helps prioritized care **Emergency Severity Index (ESI)** - Five level triage system that classifies patients based on the severity of their condition and resource needs. (higher the number, the higher the acuity) - 1 = Patients require **immediate life-saving intervention** (e.g., cardiac arrest, severe trauma) - 2 = Patients are at a **high risk for deterioration** or are in **severe pain/distress** (e.g., chest pain, sepsis) - 3 = Patients are **stable but need multiple resources** (e.g., abdominal pain, fractures, requiring imaging) - 4 = Patients are **stable, with one resource needed** (e.g., **simple laceration** with stitches) - 5 = Patients are stable and need no resources beyond a physical exam (minor colds) A **mass casualty Incident (MCI)** is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately - It **begins** with global sorting, based on patients' ability to follow commands. (1) - Next provide basic life saving interventions (\21 mm Hg, SCD, or anticoagulated.** - **Lower grades can be managed outpatient but check with the consultant first.** - Head of Bed at **45 degrees** - **Consult Ophthalmology!** 5. **Orbital Blow-Out Fractures** - MC sites - inferior wall (maxillary sinus) & medial wall (ethmoid sinus through the lamina papyracea) - Examine for other traumas, visual acuity, palpation of the face, pupil etc. - EOMs: Diplopia on upward gaze common with fracture of the inferior wall due to entrapment of the inferior rectus, inferior oblique - Get a Maxillofacial CT!! - Management includes **Ophthalmology or Maxillofacial surgery referral/consult** - Minor blowout fractures can be managed outpatient. - **May give prophylactic cephalexin and caution on nose blowing.** 6. **Orbital Hemorrhage** - **Can lead to blindness** - **Limited EOM's** - **Lateral canthotomy (incision theough the lateral campus so the globe can stand out and relief** - **Ischemia to the optic nerve** 7. **Chemical Ocular Injury** - An alkali (which ends in hydroxide). The **most common kind is ammonia or lye,** these injuries are worse than acid because it causes liquefaction necrosis. - **Acid injuries cause coagulation necrosis**. - Irrigate **with 1-2 liters of normal saline**, use a **Morgan's lens** until the **pH is less than 7.4, \~ 7-7.2** - Exams should include pH (litmus paper), slit lamp exam, and measurement of IOP. **May appreciate a cloudy cornea or epithelial defect with more significant burns**. - If minor chemical conjunctivitis, **erythromycin ophthalmic ointment**. Management may also include **cycloplegic agent and topical corticosteroids** 8. **UV Keratitis** - Intense light in the ultraviolet range from any source can cause **death of corneal epithelial cells** (snow blindness or welder's flash) - Can feel like a FB sensation, pain, photophobia, and tearing - **Pain usually comes 6-12 hours after exposure**. - Slit lamp examination reveals **diffuse punctate corneal edema, and fluorescein reveals diffuse punctate corneal abrasion-**like lesions. - pain control with **oral NSAIDs, topical cycloplegics**, and **lubricating topical antibiotic ointments.** - **Healing begins in 24-36 hours**. Consult if this is not the case **Vison Loss Conditions** Think about whether the patient is in pain or not. **Ophthalmology consultation** occurs for **any patient who presents to the ED** with acute vision loss associated with structures of the optic nerve. **Neurology, neuro-ophthalmology consults** are advised **for conditions involving and posterior to the optic nerve.** 1. **Acute Angle Closure Glaucoma** - Vision-threatening increased IOP due to the **blockage of aqueous circulation** **from its production in the posterior chamber to its absorption in the anterior chamber.** - Often precipitated by dilation of the eye/mydriasis. - **MC in older patients.** The presentation includes **acute onset monocular vision loss** with associated eye pain and HA. May report associated N/V, "halos" around lights. - Exam with fixed, mid dilated pupil, hazy (cloudy/steamy) cornea, conjunctival injection at the limbus - Diagnosis made by presentation with **elevated IOP (60 -- 80 mmHg).** - Management **includes pain and emesis control, and therapies targeted at decreasing IOP: carbonic anhydrase inhibitor (IV, PO, or topical, acetazolamide MC), topical β-blocker (timolol MC), topical α-agonist (apraclonidine MC).** - Repeat IOP measurements every hour to monitor response to treatment. May require emergency surgery if no response. - **Emergent Ophthalmology consultation!!!** 2. **Central Retinal Artery Occlusion** - **Vascular compromise to the retinal arterial vessel(s) leading to retinal ischemia. Considered a stroke equivalent with similar risk factors (+ GCA).** - Presentation is **acute, painless, monocular loss of vision, often with very poor visual acuity of finger counting or less**. May have preceding amaurosis fugax. - Fundoscopic Exam: afferent pupillary defect and a pale retina with **cherry red macula. May see "boxcarring" of retinal vessels.** - Will see skipped blood spaces but the **macula is still red because its getting blood supply from the choroid circulation.** - Treatment may involve a thrombolytic - Ophthalmology and Stroke Neurology Consultation 3. **Central Retinal Vein Occlusion** - **Thrombosis of the central retinal vein causes retinal venous stasis, edema, and hemorrhage.** - Presents with **acute, subacute, or progressive painless monocular vision loss.** - **Fundoscopic exam** classically shows **diffuse retinal hemorrhages ("blood and thunder").** May also include optic disc edema, dilated retinal veins (retinal venous engorgement), and cotton wool spots. - Other exam findings include **an afferent pupillary defect. Elevated IOP *with pain* is a late finding, "90 day glaucoma."** 4. **Retinal Detachment** - **Separation of the retina from the underlying retinal pigment epithelium and choroid.** May progress to involve the central retina. - **Monocular, progressive, painless vision loss like a curtain over a field of vision. Often preceded by fleeting "flashers" and/or "floaters"** - Increased risk if Hx of **myopia or cataract surgery.** - **Diagnosis is clinical. POCUS** confirms the diagnosis with a **billowing hyperechoic line that waves with side-to-side** movements of the eye. - Patients should be counseled to decrease eye movement (no reading, watching television, or exercising) and possible bed rest. - **Ophthalmologist consultation/referral** Eye Infections 1. **Orbital Cellulitis** - an infection of the **orbital soft tissues posterior to the orbital septum**. It is potentially life threatening and requires **hospital admission and IV abxs.** - Etiologies include bacterial rhinosinusitis, orbital trauma with fb, or ocular surgery. - Pain - with **extraocular movements** is specific to Orbital Cellulitis. - Visual disturbance -- May be abnormal in orbital cellulitis. **Diplopia or ophthalmoplegia, proptosis, and afferent pupillary defect** may be seen with orbital cellulitis. - Diagnosis may be clinical. **CT with contrast of the orbit, +/- maxillofacial/sinuses** may secure diagnosis and evaluate complications. - Blood cultures are recommended (but low yield). - Prescribe vanc and ceftriaxone 2. **Anterior Uveitis (aka Iritis)** - inflammation at any point along the uveal tract. *The uvea/uveal tract includes the iris, ciliary body, and choroid.* - Many etiologies - Variable presentation severity but may have a painful, red eye with **limbic injection, consensual photophobia**, and decreased visual acuity. - Slit lamp exam reveals **"cells and flare" -** *haziness of the anterior chamber due to leukocytes and protein* - Dx: No improvement in pain with topical anesthetics may be another clue, Start with CXR and syphilis testing - Can be connected to autoimmune diseases like sarcoidosis - Management includes **topical steroids and cycloplegics.** - Complications may include adhesion of the iris/lens, cataract, glaucoma, and macular edema. 3. **Herpes Simplex Keratitis** - Affects the eyelids, conjunctiva, and cornea. - Symptoms may include unilateral eye pain, redness, blurred vision, and photophobia. - Exam may reveal a **preauricular node**, conjunctival injection, but **fluorescein exam findings of corneal dendritic lesions and/or geographic ulceration are most common.** - May **be treated with oral or topical antivirals**. May be treated with **additional erythromycin ophthalmic ointment to prevent secondary infection.** - May lead to **corneal scarring** if **delayed treatment**. - Ophthalmology referral and follow up. 4. **Herpes Zoster Ophthalmicus** - Herpes zoster involvement of the **ophthalmic division of the fifth cranial nerve.** - Symptoms: Prodrome of headache, malaise, and fever. Unilateral pain or hypesthesia in the affected eye, forehead, and top of the head may precede or follow the prodrome. - When the rash onsets **conjunctivitis, uveitis, and keratitis may occur.** - **Hutchinson sign** = Vesicular lesions on the side or tip of the nose, indicates involvement of the nasociliary branch of the trigeminal nerve, which also innervates the globe. - **Clinical diagnosis**: Early diagnosis and treatment is critical to prevent progressive corneal involvement and potential loss of vision. - Management may include **oral acyclovir or valacyclovir, and possibly steroids.** *Immunocompromised pts or more complicated presentations may require admission and IV antivirals.* - Consult 5. **Corneal Ulcer** - A serious infection that affects multiple corneal layers, **often following epithelial damage,** allowing pathogens to penetrate the corneal stroma. - with S. pneumoniae, S. aureus, and Pseudomonas being common culprits if contact lenses are involved. - Typical symptoms include **eye redness, lid and conjunctival swelling, discharge, pain, foreign body sensation, photophobia, and blurred vision**. If the ulcer is central or uveal tract inflammation is present, visual acuity is reduced. - Examination **reveals a round or irregular hazy based ulcer extending into the stroma.** Maybe accompanied by iritis causing a miotic pupil and consensual photophobia. - Slit-lamp findings may include **"cells and flare" from iritis**, and **occasionally a hypopyon.** - Immediate **treatment involves topical antibiotics, typically a fluoroquinolone** such as **ciprofloxacin or ofloxacin**, with ophthalmologic consultation for culture and proper antibiotic therapy - Cycloplegics may be used to **ease iritis-related pain**. **ENT Emergencies** **Ear** 1. **Necrotizing (Malignant) Otitis Externa** - an invasive infection of the ear canal that spreads through **the periauricular tissue to the mastoid/temporal bone.** - **MC** causative organism **= Pseudomonas** - More common in elderly, diabetic, and immunocompromised patients. - **Presentation: non resolving OE, severe otalgia, edema/erythema/warmth of the external auditory canal, purulent otorrhea, and tenderness of the mastoid/temporal bone with palpation.** - Raised concern for include cranial nerve palsies (facial nerve, cranial nerve VII MC), parotitis, trismus. - **Dx: maxillofacial (temporal) and head CT with contrast, blood cultures, ear drainage culture, CRP/ESR.** - **Treatment: Oral vs IV abx of fluroquinolones - Ciprofloxacin, or antipseudomonal beta-lactams - cefepime or piperacillin-tazobactam.** - **Consult ENT** 2. **Acute Mastoiditis** - A suppurative infection of the mastoid air cells. **MC a complication of acute otitis media.** - MC pathogens are** S. pneumoniae, Streptococcus pyogenes, and P. aeruginosa.** - Presentation: Presents with **protrusion of the auricle**, obliteration of the postauricular crease, and postauricular/mastoid erythema, edema, and tenderness**. Also has some OM symptoms** - **Clinical diagnosis. Consider imaging with Head CT with contrast** - **Treat with ceftriaxone or levofloxacin** - **Consult/Refer to ENT. May require surgical intervention.** 3. **Auricular Hematoma** - is formed by a blunt, shearing **force to the ear,** **separating the cartilage from its vascular supply (the perichondrium).** The hematoma forms between the cartilage and perichondrium. separation of the cartilage from both **its nutrient and vascular supply** is the **primary risk factor for cartilage necrosis and scarring.** - Fibrocartilaginous overgrowth can occur over scarring, causing a **"cauliflower ear"** deformity. - Common with boxers, wrestlers, martial arts, etc. - drainage of the hematoma is recommended with either an 18 gauge needle or incision and drainage, followed by a pressure dressing. - **Re-evaluate in 24 hours for re-accumulation**. - Avoid drainage if concern for neurovascular compromise to the ear. - Consult ENT or Plastics 4. Ear Foreign Body - Urgent removal is required for **live insects, button batteries, and** any foreign bodies that may cause a **penetrating injury** to the tympanic membrane. - Consider ENT consultation for button battery and penetrating injury to the TM. - Non-emergent: irrigation, low suction, skin glue, magnet, alligator forceps. Etc. - Examine the ear canal and TM carefully after removal 5. **Cerumen Impaction** - Common symptoms include **decreased hearing, pressure/fullness in the ear, otalgia**, possible dizziness or tinnitus. - softening the wax with hydrogen peroxide, Debrox, or liquid docusate (Colace). Then irrigate. - be removed with ear loop/curette. - Risk of cerumen removal is traumatic TM perforation. RFs for perforation include previous ear surgery, previous or current OM or OE. - Call ENT if needed. 6. **TM perforation** - acute onset of pain and hearing loss, **with or without bloody otorrhea.** May also c/o transient vertigo or tinnitus - Etiologies include **secondary to AOM**, barotrauma, trauma (blunt, penetrating, or acoustic) - TM should be completely visualized. Document the perforation size in terms of percentage relative to the entire tympanic membrane. - **heal spontaneously within 4 weeks**. - mainstays of therapy include pain management with **acetaminophen and/or NSAIDs.** - Educate patients to **keep their ears completely dry**. Place a cotton ball coated in petroleum in the shower. Avoid swimming for 2-3 weeks - *Advise patients to* **avoid forceful nose blowing or performing a forceful Valsalva maneuver.** - *Refer to ENT for penetrating injury and as needed.* 1. **Epistaxis** - causes include digital trauma, deviated septum, dry air or irritant exposure, and rhinosinusitis. - **Increased risk with HTN, bleeding/clotting disorder, anticoagulation use, Etoh**. - PE: Examine in the sniffing position after a good nose blow, **Afrin (Oxymetazoline**), and trial of direct pressure. - **Anterior MC and easier to manage** - Signs possibly Posterior: bilateral bleeding, bleeding not resolved with nasal pressure/other measures, blood in the ***posterior oropharynx.*** - Management for anterior: Direct pressure with Afrin. Observe for 1 hour once bleeding controlled. Follow up with ENT in 48 -- 72 hours. - **Posterior Management: ENT Consult** - Posterior packing is not recommended, its associated with increased complications (hypoxia, arrythmia) 2. **Nasal Fracture** - Most common fractured facial bone in adults. Generally present with history of trauma, pain, and deformity. - Most common facial fractures associated with sports activities. - Clinical diagnosis. Imaging is not required unless concerned for other injury. - Manage pain and follow up with ENT and/or Plastics once edema is improving (6 -- 10 days). - Closed reduction is typically performed within 10 days. 3. **Nasal Septal Hematoma** - Associated with nasal fracture and facial trauma. - Evaluate for septal hematomas, which will appear as a white or bluish fluctuant mass. These may also cause pressure-induced avascular necrosis and can lead to subsequent "saddle nose" deformity. - Drainage of the hematoma is indicated to prevent deformity and infection. Follow with anterior packing. - ENT follow up in 24 hours. 4. **Nasal Foreign Body** - Similar to ears Mouth/Throat 1. Atraumatic Dental Pain Infections/Abscess - **pain, facial or gum swelling, heat/cold sensitivity, bad taste in mouth** - Inspect, palpate/tap gum line and teeth. Visualize the tongue to look for elevation. Palpate under the tongue to assess for bulging, firmness, or tenderness in the submental space. - **pain control** (dental block, NSAIDs, Tylenol, topical Orajel, mouth rinses), **antibiotics** (Pen VK, Amoxicillin, Augmentin, Clindamycin), and **dentistry referral.** If abscess is present, may require drainage. - If concern for deep space infection/Ludwigs angina -- secure the airway, start IV antibiotics, CT face and neck with contrast. Consult Oral/Maxillofacial Surgery. 2. **Ludwig Angina** - infection of the submental, sublingual, and submandibular spaces. Patients usually present with poor dental hygiene, dysphagia, and odynophagia. Clinical examination reveals trismus and edema of the entire upper neck and floor of mouth. Infection progresses rapidly and can posteriorly displace the tongue, causing airway compromise. Definitive airway management should be considered early, including awake fiberoptic intubation or awake tracheostomy. 3. **Post extraction alveolar osteitis, or dry socket** - Presents 2 to 3 days post operative with exquisite pain. - **Loss of formed clot from the socket** results in **exposure of the alveolar bone** and initiates a **localized osteomyelitis** of the exposed bone. - **Risk factors**: smoking, preexisting periodontal disease, a traumatic extraction, and hormone replacement therapy - Pain management is most important (irrigate or place moist gauze over the affected area - For bleeding post extraction, use direct pressure, silver nitrate, 4. **Dental Trauma** - **Avulsed tooth** is a tooth that has been completely dislodged from its socket - Handle the tooth with the crown only, not the root. - Store tooth in an **isotonic solution such as milk, 0.9% sodium chloride**, or Hank's balanced salt solution. - Irrigate the socket with saline to remove debris and blood**. Do not wipe.** Gently push the tooth into the socket and align with adjacent teeth. - Highest tooth survival seen with tooth replantation **within the first 30 minutes**. - For extrusion and lateral luxation injuries, gently move into anatomic alignment. - If there is intrusion (tooth pushed into the gum line and into the alveolar bone), do not attempt to pull/move it. Tooth will be locked into the bone. **Consider dental splint and dentistry consultation/referral.** 5. **Dental Fractures** - Ellis class 1 (enamel only) -- No specific treatment. Dentistry referral. - Ellis class 2 (extends into dentin) -- If dentin layer is thin**, cover first with calcium hydroxide base, then dental paste.** Ideally seen by dentistry within 24 hours. - Ellis class 3 (extends into the pulp) -- Same care as Ellis class 2. - Evaluate for other facial/head, neck trauma as indicated. 6. **Peritonsillar Abscess** - Often polymicrobial: *Strep, Staph, respiratory anaerobes.* - Presentation: Ill appearing, F/C, sore throat, and odynophagia. Preceding pharyngitis or tonsilitis - PE: posterior oropharyngeal/palatal edema, **displacement of the infected tonsil, contralateral uvula deviation, trismus, "hot potato voice," and LAD.** - Clinical diagnosis versus imaging **with soft tissue neck C**T with contrast. - Management includes **dexamethasone**, antibiotics (**Clindamycin, v/s Pen VK with Metronidazole)**, needle aspiration, and ENT consultation/referral depending on severity. 7. **Retropharyngeal abscess** - MC presents in younger children (2 -- 4 y/o). - Presentation: more ill with neck pain/swelling - Obtain imaging with soft tissue neck CT with contrast. - More aggressive management with admission/airway protection, IV antibiotics (**Clindamycin or Zosyn),** and **ENT consultation/evaluation** for surgery. 8. **Epiglottitis** - Increasingly a disease in adults (due to HIB vaccination). - Combination of sore throat, dysphagia, drooling, stridor/SOB. - Diagnostics may include soft tissue neck XR v/s CT or direct visualization with laryngoscopy. - Ceftriaxone and Vancomycin - Nebulized racemic epinephrine may be used for airway edema. - Consult ent **Hordeolum (Stye)** 9. Acute & painful mass in the eye, that develops abruptly (pustule on eyelid edge with erythema) Feels like a foreign body sensation Treatment: warm compress, incision pustule occurs on the inner surface of the tarsal plate. Signs and symptoms include pain, edema, and erythema of the eyelid. **Blepharitis** - Eyelash crusting, eyelids may be stuck together when they wake up - May have some erythema of the eyes - Education: clogged meibomian glands - Treatment: lid scrub with maybe a baby shampoo, warm compress, ophthalmic antibiotic ointment (bacitracin, erythromycin) - Can be associated with Rosacea **Chalazion** - Large mass in eye that has grown gradually and is painless (same foreign body sensation) - Education: clogged meibomian or Zeis (sebaceous) glands - Treatment: Typically, self-resolving but there is a surgical procedure to remove it if it does not improve **Optic Neuritis** - Acute unilateral vision loss, painful eye movements, blurry vision, loss of color vision - PE: decreased pupillary light reaction - Etiology: inflammation of the optic nerve. Most common co-morbidity is multiple sclerosis, but also lupus and Lyme disease - Dx: slit lamp, MRI brain to r/o MS - Tx: neurology referral, oral steroids (inflammation in optic nerve) **Otitis Externa** - Painful external ear canal - Patient may have had a recent experience in a swimming pool - PE: will have pain with movement of tragus or pinna, erythematous cartilage with purulent drainage, wont be able to visualize the tympanic membrane, pain with chewing - Etiology: Psuedo A. - Diabetics are at high risk for malignant otitis externa from Candida albicans - Tx: antibiotic-steroid drops (dexamethasone/ciprofloxacin). Can insert a wick if swollen - Prevent this with ear plugs while swimming, can use some acetic acid rinse, can even use a blow dryer (anything to prevent consistent moisture from being in the area) **Otitis Media** - Patient may have had a recent upper respiratory infection, ear pain, irritability, tugging at the ear, hearing loss - PE: red, bulging, thick, retracted immobile tympanic membrane. Fever - With effusion: clear, gray, amber serous fluid - Bullous Myringitis: Blood blisters on TM, deep in canal - Etiology: Infection due to an accumulation of fluids, inflammation and narrowing of eustachian tube. - Can be due to smoke exposure!! Daycare - Dx: Otoscope **Sinusitis** - Hx: loss of smell, malaise, HA, congestion, sore throat, rhinorrhea, facial pressure. Comorbid asthma. Seasonal allergies, smoker. - Chronic symptoms will last longer than 12 days - PE: sinuses tender to palpation, fever, cannot transilluminate sinuses - Dx: x-ray (water's view) CT scan if chronic Tx: Nasal saline, humidifier, Abx= Bactrim, augmentin, oral steroids = prednisone, may do nasal steroids (flonase) expectorants (guaiffenesin or musinex = drinking **Pharyngitis** - Strep Throat - Sore throat, odynophagia, no cough (ask about cough, if they have one, not strep!!) - PE: fever, tonsillar exudate, edema and erythema, cervical lymphadenopathy - Dx: Rapid Strep Swab (GET TWO) - Tx: ABX (amoxicillin, maybe pen) saltwater gargles may help with some pain and inflammation. Benzocaine lozenges...If you feel like your symptoms aren't improving come on back and see us because simple strep throat can turn into further complications if we don't handle it adequately **Envenomation** Snake envenomation involves the presence of a snakebite **plus evidence of tissue injury** **Differentiate snake envenomation presentations and describe management considerations.** **Pit Vipers (Crotaline)** include rattlesnakes, copperheads, cottonmouths (Water Moccasins) - **Heat-Sensing Pits**: The term \"pit viper\" comes from the pair of **specialized heat-sensing pits located between their eyes and nostrils**. These pits detect infrared radiation (heat) from warm-blooded animals, allowing the snake to accurately target prey, even in low light or darkness. - **Triangular Head Shape**: Pit vipers have a characteristic broad, **triangular head that is wider than their neck.** This head shape helps distinguish them from non-venomous snakes. - **Vertical Pupils**: Pit vipers have elliptical, vertical (slit-like) pupils, as opposed to the round pupils seen in non-venomous snakes. - **Fangs**: These snakes have long, hollow, **retractable fangs** that they use to inject venom deep into their prey. The fangs fold back against the roof of the mouth when not in use. Effects of **Pit Vipers** Venom - **Local Effects (Cytoroxic)**: Typically, pit viper envenomation causes **immediate pain, swelling, and ecchymosis** at the bite site. Swelling may rapidly progress and involve the entire limb. Other local signs include blistering, necrosis, and hemorrhage due to tissue-damaging enzymes in the venom. - **Systemic Effects**: Systemic signs may include nausea, vomiting, **hypotension, coagulopathy (e.g., elevated PT/INR, decreased platelets), and neurologic effects** like paresthesia. In severe cases, there may be cardiovascular instability. **Coral Snakes** include Eastern coral snakes, Texas coral snakes, and Sonoran coral snake - **Coloration**: Coral snakes have distinctive**, bright color patterns** with bands of red, yellow (or white), and black. In the U.S., a helpful mnemonic to distinguish them from non-venomous look-alikes (such as the harmless kingsnake) is "Red touches yellow, kill a fellow; red touches black, friend of Jack." However, this mnemonic does not apply to coral snakes found outside of the U.S. - **Small Head and Round Pupils**: Coral snakes have a **small, rounded head** that is not distinctly broader than their body, unlike the triangular heads seen in pit vipers. They also have round pupils, rather than the vertical slits seen in vipers. - **Small Fangs**: Coral snakes **have small, fixed (non-retractable) fangs** at the front of the mouth, which are not as long as those of vipers. Because of this, they **must chew or hold onto their prey to inject venom effectively.** **Coral Snakes Effects** - **Neurotoxic Venom**: Coral snake venom is primarily neurotoxic, which means it affects the nervous system. The venom disrupts neuromuscular signaling, potentially leading to paralysis. This type of venom is different from the hemotoxic venom of pit vipers, which causes local tissue damage. - **Delayed Symptoms**: Symptoms of envenomation may be delayed, sometimes taking several hours to appear, making it easy to underestimate the bite\'s severity. Initial symptoms might include mild pain or numbness at the bite site, followed by neurological symptoms such as difficulty speaking, swallowing, muscle weakness, and, in severe cases, respiratory paralysis. - **Low Injection Rate**: Coral snakes must "chew" or hold onto their prey to inject venom effectively. Because of this, envenomation occurs less frequently than with viper bites. **Snake Bite First Aid Tips** - Be calm, limit movement - Remove any items such as rings, watches, or jewelry **that might become tight as swelling occurs.** - The affected limb should be **stabilized with a loose splint and elevated to heart level or higher to reduce swelling.** - Pressure immobilization bandages are **not** recommended for pit viper bites. - Certain actions taken before EMS arrival, such as cutting, suction devices, electroshock/tasers, tourniquets, and ice**, have been shown to be ineffective or harmful.** - **If symptoms do not develop w/in 8 to 12 hours, a dry bite has occurred!** **Proper Snake Bite Evaluation** - Place the patient on a monitor and establish IV access in an unaffected limb. - Elevate and maintain pain control - Mark the leading edge and **document circumferential extremity exam** with **serial exams (q 15 mins, q 1 hour after stabilized).** - Consult with toxicology or poison control - **Most Important**: Administer CroFab repeatedly until the progression of swelling, pain, any systemic symptoms, and laboratory abnormalities improve. **Expected Labs and Their Possible Result for a Snake Bite Patient** **CBC** - assess for anemia, hemolysis, leukocytosis, and thrombocytopenia. - **Leukocytosis**: Common in response to stress or inflammation from envenomation. - **Thrombocytopenia**: A possible result of **hemotoxic effects, particularly in pit viper** bites, which can cause platelet aggregation and consumption. - **Hemolysis**: Especially with **pit viper bites**, which may lead to **decreased hemoglobin and hematocrit.** **Coagulation Studies to include PT, PTT, INR, Fibrinogen, D-Dimer** - To evaluate coagulopathy, which is a common effect of pit viper venom. - **Prolonged PT and PTT**: The venom may disrupt clotting factors, leading to coagulopathy. - **Elevated INR**: Reflects impaired blood clotting ability. - **Decreased Fibrinogen**: Suggests consumptive coagulopathy and fibrinolysis. - **Elevated D-Dimer**: Indicates ongoing fibrinolysis, **potentially signaling disseminated intravascular coagulation (DIC).** **Creatine Kinase** - **evaluate for muscle injury or rhabdomyolysis**, which can occur from venom-induced tissue damage or prolonged immobilization. - **Elevated CK** indicates muscle breakdown **Blood Type and Crossmatch** - **Purpose**: If there is a risk of significant hemorrhage or if the patient requires a transfusion due to coagulopathy, this preparation is necessary. - **Expected Action**: Crossmatch only needed if bleeding risk is high or severe anemia develops. **Antivenom Process** - The initial dosing is 4-6 vials - Patients with more severe systemic envenomation should receive 10-12 vials - Reassess every 15-30 minutes for the first 2 hours. - are no signs of systemic toxicity and local symptoms do not progress, the interval of reassessment can be extended to every hour for 12 hours, followed by intervals of 2-4 hours. - If local symptoms continue to worsen or systemic and/or hematologic signs are present, an additional 4-6 vials of CroFab **Snake Bite Disposition** - If dry bite, discharge to home after 8 -- 12-hour period of observation with strict return precautions. - give antivenom and closely monitor with admission (possibly ICU). - May develop angioedema and other signs of allergic reaction. Treat appropriately. - Provide proper wound care, including Tetanus booster if needed. - If symptoms progress, **MORE ANTIVENOM!** **Recognize the presentation of a Hymenoptera sting and manage appropriately (depending on severity)** Hymenoptera stings (e.g., from **bees, wasps, hornets, and fire ants)** can lead to a variety of reactions, ranging from mild localized effects to severe, life-threatening anaphylaxis. - **Local reactions** may include **pain, redness, swelling, and itching** confined to the sting site. Symptoms may last for a few hours to a couple of days. - **Toxic Reactions** may occur after **multiple stings,** causing a high venom dose that can lead to systemic toxicity. Symptoms may include headache, fever, vomiting, diarrhea, muscle breakdown (rhabdomyolysis), and kidney injury. **Management of Hymenoptera Stings** - **Remove the Stinger**: If from a bee sting, gently scrape it out with a **flat object (Credit Card)** to minimize additional venom release; avoid squeezing the stinger. - **Cold Compress**: Apply **ice or a cold compress** to reduce pain and swelling. **Heat makes it worse.** - **Pain Relief**: Use NSAIDs or acetaminophen as needed. - **Antihistamines**: **Oral antihistamines** (e.g., diphenhydramine) can help alleviate itching and reduce mild swelling. For more significant reactions, **consider oral steroids, and antihistamines, both Benadryl and Famotidine (Pepcid)** - **Topical Treatments**: Hydrocortisone cream or calamine lotion may soothe itching and redness. - **Observation**: Generally, no further follow-up is needed unless symptoms worsen or are not resolved. - **Recognize the presentation of anaphylaxis and manage appropriately.** Symptoms generally develop within minutes, including: - **Respiratory symptoms** (wheezing, difficulty breathing, throat tightness) - Cardiovascular symptoms (**hypotension, dizziness, tachycardia**) - Skin reactions (generalized urticaria, **angioedema**, itching) - **Gastrointestinal** symptoms (nausea, vomiting, diarrhea, abdominal cramps) - **Oral Symptoms** may include itching of the lips, metallic taste etc - **Neurologic symptoms** may include anxiety, seizure, or headache Management of Anaphylaxis - **IV Solumedrol 125 mg, IV Benadryl 25 -- 50 mg, and IV Pepcid 20 mg PLUS IM Epinephrine (1:1000) 0.3-0.5mg anterolateral thigh, repeat q 5 min as needed, and close monitoring.** Anaphylaxis Deposition - **Most Hymenoptera stings require only supportive care, management of local reaction, and reassurance.** - At time of discharge if anaphylactic reaction: Counsel on avoidance, prescribe Epi pen, refer to an allergist/immunologist, and consider carrying medical identification (e.g., medical alert tag) for stinging insect hypersensitivity. **Differentiate spider bite envenomation presentations and describe management considerations.** **Loxosceles reclusus (Brown Recluse)** cytotoxic and hemolytic **Presentation**: Loxoscelism usually results in a necrotic ulcer at the bite site. Symptoms may include **initial redness, and sometimes itching, but typically no pain as it may go unnoticed for several days.** Over hours to days**, a red, white, and blue target lesion may form, leading to blistering, and ultimately ulceration and necrosis.** Systemic symptoms are rare but can include fever, chills, malaise, and, in severe cases, hemolysis and kidney injury **Bite Site**: The lesion often becomes painful and may progress to necrosis, typically localized rather than systemic. Symptoms may develop within 24 -- 78 hours and include F/C, myalgias and arthralgias, thrombocytopenia etc. but this rarely occurs. **Brown Recluse envenomation Management** - **Wound care**: Local wound care is crucial, including cleaning, debridement if necessary, and sometimes antibiotics if secondary infection is suspected. - **Pain control**: NSAIDs or acetaminophen for pain management. - **Antibiotics**: Not generally needed unless there is secondary bacterial infection. - **Tetanus prophylaxis**: Update if necessary. - Immobilize/Ice/Elevate Latrodectus mactans (BLACK WIDOW) - **Presentation**: The classic sign is ***latrodectism***, a syndrome characterized by **intense muscle pain, cramps, and spasms**, often in the abdomen, back, and chest. The pain can be severe, with symptoms like sweating, tremors, and autonomic instability (e.g., hypertension, tachycardia). Patients may feel anxious or have nausea and vomiting. - **Bite Site**: Initially, a widow spider bite might cause mild pain or go unnoticed, but **within 15 minutes to an hour, systemic symptoms typically develop**. - Increasing and spreading pain develops. - **Erythematous macule develops into a target lesion with a blanched center and surrounding erythema** - Cramping starts locally, around the area bitten. Then commonly extends into large muscle groups, such as the abdomen, back, chest, and thighs. Muscle rigidity may be appreciated on exam. - May mimic an acute abdomen picture. - Other symptoms may include: HA, fine tremors, photophobia, N/V, and SOB. **Black Widow Envenomation Management** - **Pain control**: Opioids may be required for severe pain, and benzodiazepines can help reduce muscle spasms. - **Antivenom**: Latrodectus antivenom is available for severe cases with significant systemic symptoms, though it\'s reserved for cases refractory to supportive care due to possible allergic reactions. - **Supportive care**: Muscle relaxants (e.g., benzodiazepines) and IV fluids as needed for symptom control. - **Monitoring**: Hospital admission may be necessary for severe envenomation with autonomic instability or refractory pain. **Manage a mild jelly fish sting.** - Jellyfish have stinging venom containing **nematocysts mainly on their tentacles**. - Stimulus triggers a harpoon like release of a threadlike tube from the nematocyst which penetrates and envenomates the skin. - Severity of envenomation depends mainly on the marine species. - In the US, most jellyfish stings are mild, local skin reactions -- wheal formation, erythema, and stinging pain. - **Management:** irrigate with seawater, remove any remaining nematocysts, and follow with hot water immersion. Topical lidocaine is helpful for pain. Skin & Soft Tissue Emergencies **Perform an evaluation of a puncture wound and address common complications.** - **Mechanism of Injury**: Understand what caused the puncture (e.g., nail, animal bite, or sharp object) to determine the risk of infection or foreign body retention. **Typically, a high pressure or bite wound. (**Site of the wound is **typically plantar)** - **Time Since Injury**: **Older wounds** are more susceptible to **infection.** - **Environment**: Injuries occurring in dirty or outdoor environments carry a higher risk of contamination. (Contamination and foreign body materials.) - **Health Conditions**: Identify any underlying health conditions (e.g., diabetes, immunosuppression) that may impact healing and increase infection risk. **PE for a Puncture Wound Assessment** - **Wound Location and Depth**: Measure the wound and note the location, especially if near vital structures like joints, tendons, or bones, as deeper punctures may increase infection risk. - **Signs of Infection**: Look for redness, warmth, swelling, or purulent discharge around the wound. - **Presence of Foreign Material**: Evaluate for visible foreign bodies (e.g., debris, glass, or splinters) and consider whether imaging may be needed for non-visible material. - **Neurovascular Status**: Check for adequate blood flow, sensation, and motor function in the area surrounding the wound, especially if it is near nerves or blood vessels. **Steps to Evaluate Possible Foreign Body with Punch Wounds** - **Presentation**: Patients may feel pain or discomfort at the wound site, and infection may develop if foreign material is left inside. - I**maging**: X-rays can detect radiopaque materials like metal or glass, while ultrasound is useful for organic materials (e.g., wood). - **Removal**: Remove any identified foreign bodies under sterile conditions to reduce infection risk. - **Tetanus Prophylaxis**: **Determine Tetanus Status**: Administer a tetanus booster if: It has been more than 5 years since the last dose, particularly for high-risk wounds. **Puncture Wound Management** - Clean and irrigate the wound - Consider **prophylactic antibiotics** if: - **High risk puncture** -- plantar puncture, bite wounds, contaminated wounds - High risk patient -- DM or immunosuppressed - For **plantar puncture wounds** through athletic shoes, **an oral fluoroquinolone with antipseudomonal activity** (ie ciprofloxacin, levofloxacin) is recommended***.*** - If persistent or worsening pain, consider a missed FB or developing abscess. - Don't forget to **check tetanus status** (for all wounds), document and/or booster. **Recognize the presentation of skin and soft tissue emergencies and initiate appropriate management in the ED setting.** **Foreign Body** - **Mechanism of Injury**: Ask about how the foreign body became embedded (e.g., stepping on an object, traumatic injury, or accidental ingestion/inhalation). This provides clues about potential depth, contamination, and complications. - **Time of Injury**: Foreign bodies that have been in place longer may increase the risk of infection and may be harder to remove due to tissue inflammation and scarring. - **Type of Foreign Body**: Identify the material, if possible (e.g., wood splinters, teeth fragment, pins/needle, glass, metal, plastic), as some materials (like organic matter) increase infection risk. **PE for a Foreign Body** **Inspection:** Carefully inspect the wound for visible foreign material or changes in skin color or texture that might indicate a foreign body beneath the surface. **Palpation:** Gently palpate the area to identify tenderness, firmness, or swelling that could suggest the presence of a foreign body. **Signs of Infection:** Look for redness, warmth, swelling, or purulent discharge around the site, which may indicate that the foreign body has led to an infection. **Assess Functional Impact:** Check nearby structures for any deficits, such as limited range of motion, altered sensation, or vascular compromise, especially if the foreign body is near nerves, tendons, or blood vessels. **Imaging for Foreign Body** - **X-Ray**: Often the **first imaging modality used**, particularly effective for detecting **radiopaque materials** (e.g., metal, glass, some plastics). X-rays are less effective for organic materials like wood. - **Ultrasound**: Useful for locating **non-radiopaque foreign bodies** (e.g., wood or plastic) and is also effective in soft tissues. Ultrasound can also help guide removal by providing real-time visualization. Fishhook Removal **Advance and Cut (MC)** - **Local Anesthesia**: Administer a local anesthetic (e.g., lidocaine) around the entry site to ensure patient comfort, as this method involves pushing the hook further through the skin. - **Push the Hook Forward**: Grasp the shank of the hook and gently advance it forward through the tissue until the barb comes out through a new exit point in the skin. - **Angle the Hook**: Direct the hook to exit at an angle that minimizes tissue trauma. The goal is to bring the barb fully out of the skin rather than trying to pull it back through the original entry wound. - **Cut the Barb Off**: Once the barb is visible outside the skin, use wire cutters or heavy-duty scissors to cut off the barb from the hook. - Ensure you have sturdy enough tools to cut the hook, as fish hooks are often made of strong metal that can be difficult to sever. **Bite Wounds Cat, Dog, *Human, & other*** - **Cat & Dog bites** are associated with **Pasteurella multocida**. **Human bites are polymicrobial.** - Clean and irrigate well. Debride devitalized tissue. - Superficial wounds with adequate bleeding control are left open. - Prophylactic antibiotics are recommended! 3 to 5 day course of **Augmentin** MC used. - Animal bites -- Booster Tetanus as needed. Is rabies vaccination indicated? **Fish Wounds** - Fresh water wounds: - Coverage for ***Aeromonas*** *(and staph, strep)* - fluoroquinolone or **trimethoprim-sulfamethoxazole** - Saltwater wounds: - Coverage for ***Vibrio*** - fluoroquinolone or **doxycycline**