Environmental Emergencies
ABC and not CAB as main problem is ventilation and hypoxia.

C-spine injuries are extremely rare in preadolescent patients.

The most common complication of resuscitation in drowning victims is vomiting and
aspiration of vomitus. Abdominal thrusts or Heimlich maneuvers should not be performed in
this situation.

HPI - duration of immersion, events leading up to the immersion, extent of resuscitation at
the scene, and the presence of pre-existing medical conditions (including history of seizures,
arrhythmias, or prolonged QT syndrome).

There is no clinical difference between fresh-water and salt-water drowning.

The administration of glucocorticoids or prophylactic antibiotics is not routinely recommended.
Hypothermia is defined as a body core temperature less than 35°C. Temperatures between
35°C and 32°C are categorized as mild, between 28 - 32°C as moderate, and severe
hypothermia is <28°C.

Absence of shivering in hypothermic patients is concerning, as this commonly correlates
with moderate to severe hypothermia.

For patients with moderate hypothermia, using forced air warming is the favored approach
for active external rewarming.

The vasodilation after such warming allows the cold, acidic blood from the periphery to flow
back into the central circulation, resulting in further core cooling that is known as “after

The vasodilation may also result in hypotension, necessitating aggressive intravascular
volume expansion.

The size of the Osborn waves or J waves is proportional to the degree of hypothermia.
Fish envenomation
The best immediate treatment for all fish envenomation involves immersion of the affected
body part in very hot water. The soak should continue for 30 to 90 minutes and can be
repeated if the pain reoccurs. Local infiltration of anesthetic or regional block will also provide
pain relief.

Patients with hand or foot injuries should be started on prophylactic antibiotics, with
amoxicillin/clavulanic acid being a good first choice.

Foreign body imaging is recommended, but would not be the best immediate treatment.
Altitude Sickness
Dexamethasone is used in the prevention and treatment of AMS and HACE and HAPE.
  Also recommended are supplemental O2, descent to lower altitude if HACE and HAPE

Acetazolamide and slow ascent are used to prevent AMS during an ascent.

Nifedipine can prevent HAPE and temporize its effects.
Core temperature needs to above 35°C before brain death examination can be performed.

The child needs to be declared brain-dead before discussing organ donation with family.

It is important to rule out all potentially reversible causes of brain-dead state before
considering brain death diagnosis.
Brain death / Organ Donation
Primary Effects of pressure – barotrauma from initial increased pressure of the explosive
detonation and rarefaction of the atmosphere immediately afterwards. Injuries to air-filled
organs and air-fluid interfaces. Ruptured tympanic membranes, globe rupture and
hyphema,  alveolar-capillary interface disruption, hemorrhage, contusion,
pneumohemothorax, pneumomediastinum, and subcutaneous emphysema, pulmonary
disruption causing acute gas embolization, coup contrecoup, concussion, Ruptured hollow
viscera (eg colon ) Solid organ rupture, infarction, ischemia, and hemorrhage.

Secondary Effects of projectiles – metallic and other fragments, Includes Penetrating
trauma and Fragmentation injuries

Tertiary Effects of wind – structural collapse and/or persons being thrown by blast
   wind Crush injuries: crush syndrome (metabolic derangement from damage to muscle
   tissues  release of myoglobin, urates, potassium, and phosphates  oliguric
   renal failure) Compartment syndrome, Blunt trauma, Penetrating trauma, Closed and open
  fractures, Traumatic amputations,  Closed and open brain injuries.

Quaternary Burns (chemical or thermal), toxic inhalation, radiation exposure, asphyxiation
(including carbon monoxide and cyanide), coal or asbestos containing dust inhalation, burns
Asphyxia and Exposure to toxic inhalants.
Blast and Explosion related Injury
Both diagnosed by co-oximetry. CO cause cherry red and MethHb cyanosis.

SATS will remain normal in CO but low in Methhemoglobin ( 85-89%)

PO2 on blood gas is normal in both.

Both shift the curve to left.

Symptoms at 5-10% COhb and > 1% MethHb

Co poisoning treatment - High-flow oxygen and Hyperbaric oxygen

MethHb treatment - Oxygen and methylene blue.
CO Poisoning & Methemoglobinemia