A 42-year-old farmer is working in a field when the tractor he is operating is struck by lightning. He loses consciousness at the scene and is subsequently confused. He is brought in to the ED by his colleagues. On arrival, he is hemodynamically stable but remains confused.
Which of the following is TRUE about this patient’s lightning injury?
Correct Answer: C
Lightning injuries are high-energy direct current injuries. These highenergy injuries confer considerable morbidity and mortality, ranging from cutaneous burns, neurologic injury, cardiopulmonary insult, blast effect (trauma), and others. Patients who sustain high-energy electrical and lightning injuries are (C) at higher risk of developing cataracts and should be evaluated by ophthalmology on presentation. Choice (A) is incorrect because high-voltage alternating current injuries, such as those in most industrial or household settings, are more likely to cause extensive tissue damage and cutaneous burns than direct current injuries. Lightning strike injuries can have considerable neurologic effects. Choice (B) is incorrect because paralysis that occurs from a lightning strike injury most commonly affects the lower extremities and is transient, lasting a few hours, after which sensory and motor function returns to normal. A “contact injury” (D) refers to when a patient is in contact with a structure or object that has been struck by lightning. A “ground current” refers to when lightning strikes the ground near a victim and transfers current to the patient.
Reference:
An 80-year-old female is found down at a bus stop. The outdoor temperature is 25°. She is unresponsive with shallow breathing and is intubated on the scene. She has palpable carotid pulses and is brought in by ambulance to the ED. Her core temperature is 78°F. Her initial blood pressure obtained is 90/45. Two large bore IVs are placed. Wet clothes are removed and active external rewarming is initiated. On recheck of her temperature 2 hours in, it is only 82.
What is the RECOMMENDED technique for rewarming of this patient?
Correct Answer: B
This patient has severe hypothermia, as defined by a core temperature of less than 82° Fahrenheit. These patients are often unconscious. The complications of severe hypothermia can include coma, hypotension, bradycardia and other arrhythmias, and pulmonary edema. For patients who are severely hypothermic, active rewarming should be initiated in a stepwise fashion after all wet clothes have been removed and active external rewarming is initiated. First, warmed IV crystalloid can be delivered along with warmed, humidified oxygen. If additional measures are needed, (C) irrigation with warmed fluids to the peritoneum or thorax can be considered, although this comes with possible complications. If these measures all fail, (D) ECMO can be considered in extreme cases but is not the first step of rewarming.
References:
A group of five people present to the emergency department after an unknown substance was released in the subway. They have headaches, blurry vision, rhinorrhea, and are mildly short of breath, and some are vomiting. It is believed that sarin gas was released.
Which of the following is the BEST management of patients with the most severe symptoms from sarin gas?
The mechanism of action of sarin gas is as an acetylcholinesterase inhibitor, in which acetylcholine accumulates in the neuromuscular junction, resulting in a cholinergic syndrome, with miosis, rhinorrhea, wheezing, vomiting, and diarrhea. Treatment is indicated, and (A) IV fluid resuscitation and close monitoring in the ICU alone would not be appropriate. The severity of the symptoms can vary. For patients with mild effects, including miosis alone or miosis and severe rhinorrhea without other effects, (B) the anticholinergic agent atropine should be administered, but this is not sufficient for patients with moderate effects from sarin gas. For patients with moderate effects, including respiratory distress, nausea, vomiting, weakness, or fasciculations, (C) both atropine and pralidoxime should be administered. (D) Hydroxocobalamin should be administered to patients with cyanide poisoning but is not indicated in sarin gas poisoning.
References :
A 45-year-old male is working at a nuclear facility when there is a radioactive leak. He goes to the ED where his clothing is removed and he is washed with soap and water. At the time, he was not manifesting any signs or symptoms of radiation exposure. He follows up with his PCP a month later, where he is found to be pancytopenic with white blood cell count 1.5 (absolute neutrophil count 1000), hemoglobin 6.0, and platelet count 50. He is transferred to the ED.
Which of the following is TRUE about the management of this patient’s radiation injury?
Patients who sustain radiation injury do not always immediately manifest symptoms. After decontamination, patients may not begin to show effects for 1 to 2 weeks. Cytopenias are a common manifestation and should be managed with supportive care, including (B) blood product transfusion with irradiated, leukoreduced products and G-CSF in the case of leukopenia. Transfusion thresholds are similar to those used in oncology patients, with goal hemoglobin of at least 7 to 8 in asymptomatic patients. (A) Empiric antibiotics are not recommended unless the patient is significantly neutropenic (ANC<500). Although these patients are at increased risk of infection, antibiotics should only be started when there is clinical evidence of infection. (C) Stem cell transplant can be indicated as a treatment for profound cytopenias, but initial management is supportive and stem cell transplant is not the first step. Finally (D) trending labs with no intervention would not be appropriate, and supportive care should be initiated.
A 78-year-old female with a history of alcohol abuse is found down on a park bench in the middle of a summer day, in which the external temperature is 95° Fahrenheit. She is found to be able to answer yes or no questions and follow commands but is listless and lethargic. She is brought in by ambulance, and on arrival her:
Her GCS is 13, and she smells of alcohol.
What is the BEST next step in the management of this patient?
Correct Answer: D
This patient is presenting with severe hyperthermia (or heatstroke). The elderly are at an increased risk for developing heatstroke, as are patients who have ingested alcohol and other drugs. This tends to occur particularly when the external temperature is elevated, and in patients who have increased susceptibility due to being elderly or having other medical conditions that make them increasingly susceptible. Diagnosis is based on elevated core temperature (generally greater than 104°F), in addition to altered mental status, in the setting of extreme heat exposure. Initial management for severely ill patients can even involve intubation, volume resuscitation, and vasopressors if needed. The patient described above does not need to be intubated, but rapid cooling should be initiated. Cooling should involve (D) evaporative and convective cooling techniques, which can include spraying the patient with a mist of lukewarm water, and in the setting of this benzodiazepines can be used to control shivering as needed. In addition, ice packs should be applied to the axilla, groin, and neck to cool the core areas at the location of major blood vessels. (A) Dantrolene has not been shown to be of benefit in the case of nonmalignant hyperthermia. (B) Although peritoneal lavage is an option for cooling, it is preferable to start with less invasive options, and only escalate if absolutely necessary. (C) Treatment with acetaminophen around the clock has not been shown to be beneficial in the management of heatstroke.
Click to expand