Environmental Medicine Or How to not let Mother Nature kill You Ma hew Puderbaugh, DO Capt, USAF, MC, FS 88 MDG, WPAFB, OH Objec ves
• Iden fy the different types of Heat Injuries and common treatments • Iden fy the different types of Cold Injuries and common treatments • Iden fy the importance and treatment of Al tude Injuries • Know preventa ve measures against the common vectors that transmit disease Overview
• Cold Injuries • Heat Injuries • Al tude Injuries • Vector Preven on Cold Injuries
• Localized – Chilblain – Trench foot – Frost nip/Frost Bite • Systemic – Hypothermia Windchill1 Chilblains/Pernio2,3
• Localized inflamma on secondary to cold – Dorsal aspect of digits common – Erosions, ulcers, blisters rare • Affects Young Women preferen ally • Treatment: – Preven on is key (maintaining core body temp, layering clothes) • Differen al: – Cryoglobulinemia – Raynaud Phenomenon – Chilblain Lupus Erythematous – CML – An phospolipid Anitbody Syndrome Trench foot
• Immersion Injury – Immersion Foot • Due to prolonged exposure – Does not require freezing (can occur up to 60°F) • Foot swells and discolors • Treatment: – Preven on is key – Can last up to 3-6 months – Keep dry, rewarm with warm water if needed – Amputate if gangrenous may be necessary Frostbite4,5 • Exposure Injury – Tradi onally affected military – Now mountaineers and outdoor enthusiasts – 28°F (-2) is when damage occurs, can occur at 35 (2) • Risks: – PVD/Diabetes/Smoking – Raynaud’s, Sepsis, Alcohol/ Drugs use, – Psychiatric illness/demen a – Trauma/Homelessness • Treatment – Old: only rewarming and preven on of infec on – New: TPA Stages of Frostbite
Level 5 Treatment of Frostbite TPA and Frostbite4 Hypothermia6
• Loss of ability to sustain core body temperature • Classifica on: – Mild: <35°C (95°F) – Moderate: <32°C (90°F) – Severe: <28°C (83°F) – Profound: <22°C (72°F) – Popsicle: <0°C (32°F) Hypothermia Treatment6 • Preven on! • Monitoring – Art Line/IV lines – Cardiac Monitoring • Overall – A,B,C’s • Intubate if needed • Chest compressions? – Labs/Rads • Rewarming – External • Blankets (Passive): 0.5-2 °C /h • Heated blankets/BAIR hugger (Ac ve): 0.8°C/h – Internal • Warm IVF/O2: 1-2°C/h • Peritoneal exchange, esophageal warming: 1-2°C /h • NOT DEAD UNTIL WARM AND DEAD Hypothermia
• J-Wave: appears at core temperature <34°C (93°F) Hypothermia Treatment6
• Mild Hypothermia: passive external rewarming typically sufficient • Moderate Hypothermia: ac ve external rewarming of trunk (prevent a erdrop) • Severe/Worse Hypothermia: invasive techniques – Can try CP bypass and Hemodialysis in severe cases Heat Injuries7 • Mild Heat Illnesses • Severe Heat Illnesses – Miliaria rubra (heat – Severe Sunburn rash) – Heat Exhaus on – Heat syncope – Heat Stroke – Heat cramps
Wet Bulb Globe Thermometer10
• Consists of 3 Thermometers: – Black Globe (G) – Dry Globe (A) – Wet Globe (W) – 0.2G + 0.1A + 0.7W Miliaria Rubra/Prickly Heat8
• Most common in tropical environments • Typically affects non-acclimated individuals – FRACU, poten al risk? • Treatment: – Wash with soap and water – Hypoallergenic lo on – Chlorhexidine lo on, salicylate 1%, emycin cream are also op ons – Removal of poten al irritants – Takes a week or longer to clear up Mild Heat Illnesses
• Heat Cramps – Post-exer on secondary to electrolyte loss – Tx: Cool down, electrolyte replacement – Don’t confuse for exer onal sickling • Heat Edema – Typically affects elderly, non-acclima zed – Tx: eleva on of extremi es, hydra on, compression stockings • No Diure cs • Heat Syncope – Temporary circulatory insufficiency secondary to pooling of blood in peripheral veins – Tx: hydra on, counseling, r/o of other diseases Severe Sunburn
• Damage to skin secondary to UV radia on – Natural – Ar fical (tanning beds, phototherapy devices) • Prevalence: 34% in US • Risk: – Highest at noon – Cloud cover offers minor protec on – Al tude increases risk – Reflec on from snow (90%), sand (15-30%), and water (5-20%) also increases risk • Tx: – Aloe-vera/calamine – NSAIDS (oral or topical) – Topical An microbials PRN Chronic Damage • Darker skin types have slightly more protec on • Increased risk for melanoma and BCC • Ac nic keratosis – Occasionally progress to SCC • Chronic Ac nic Derma s – Typically men over 60 What Sunscreen to Recommend • Recent FDA changes to labeling – SPF does not effec vely measure protec on from UVA • Broad Spectrum – Protects from both UVA/UVB – Ranges from 15-50+ – Water Resistant: SPF maintained a er 40 min of water ac vity – Very Water Resistant: SPF maintained a er 80 min • For most people: – Broad Spectrum – > 30 SPF, 1oz per total body applica on – Apply 15-30 min before exposure, reapply q2h Examples (not endorsements)
• Use 1 oz at a me • Reapply frequently (q2h) • Reapply a er water exposure Preven on
• Tanning beds do not reduce risk of sunburn! • Protec ve Clothing: – Broad brim hats – Long sleeves – Fabric: dark- colored, thick, ghtly woven Heat Exhaus on
• Temperature is < 40°C – Clinical syndrome of volume loss – Water and salt loss – Replacement is subop mal in volume/ solute • Symptoms: – Malaise, fa gue, headache, – N/V, cramps, Diaphoresis – No altera on in mental status • Signs: – Possible eleva on of hepa c transaminases • Treatment: – IV fluids--a en on to rate of sodium correc on – Cool Down quickly Heat Stroke • Core Body Temp >40°C (but not always) – Body has lost ability to thermoregulate • Symptoms: – + CNS dysfunc on • Look for retrograde amnesia – Dry hot skin – Constricted Pupils • Treatment: – Ice water Immersion – Stop cooling at 38.5°C (101-102°F) • Can cause hypothermia • Preven on – Acclima za on (10-14 days) – Rest 1 week before return to ac vity Al tude Illness
• Acute Mountain Syndrome • High Al tude Pulmonary Edema • High Al tude Cerebral Edema • Decompression Sickness Acute Mountain Syndrome • Symptoms: – Headache PLUS – Fa gue – Weakness – Dizzy/Lightheaded – Nausea/Vomi ng – Anorexia – Sleep disturbance • Treatment: – Get down – Acetazolamide HAPE/HACE
• HAPE – Symptoms –Fa gue, weakness, dyspnea, decreased exercise tolerance, delayed recovery from exer on – Signs –Tachypnea, tachycardia, cough, frothy sputum, cyanosis, rales, decreased SaO2, patchy infiltrates – Occurs 2-4 days, >2500 m (8,200 ) • HACE – Acute Mountain Sickness PLUS • Altered mental status OR ataxia – Altered Mental Status AND ataxia • Basically worsening Acute Mountain Sickness • Tx: – Descend (as quickly as possible) – Supplemental Oxygen Decompression Sickness
• 2 Types – Type I: Joint Pains “The Bends” – Type II: Neuro, Chokes, Staggers, Cu s Marmorta • Causes: – Ascent from 33 (10m) – Exposure to >18K (5490m) – Flying a er diving – 12-48h surface interval depending on dive – DCS seen at 4,500 cabin al tude 3hr post-dive • Treatment : – 100% O2, aviator mask/NRBM – chamber ride Vector Borne Diseases
• Mul ple Diseases • Mul ple Vectors – Mosquitos – Ticks – Flies – Kissing Bugs – Bats – Rodents Vectors
• Preven on is Key when it comes to Vector Disease! Vectors
• Know where you are going • Know the Risks: – Travax – State Dept – CIA Factbook – Na onal Center for Medical Intelligence • Preven on is always best! Summary
• Iden fy the different types of Heat Injuries and common treatments • Iden fy the different types of Cold Injuries and common treatments • Iden fy the importance and treatment of Al tude Injuries • Know preventa ve measures against the common vectors that transmit disease References
1. NOAA (2015). NWS Windchill Chart. Accessed on 11 Apr 15. h p://www.nws.noaa.gov/om/winter/windchill.shtml 2. Derm101 (2015). Chilblains/Pernio. Accessed on 11 Apr 15. h p://www.derm101.com/therapeu c/perniochilblains/ 3. Olin, J.W. (2008). Other Peripheral Vascular Diseases. In Goldman, L., & Ausiello, D. (Eds.), Cecil Medicine 23rd Ed. (pg 568-569). Philadelphia: Saunders Elsevier. 4. Handford, C. (2014). Frostbite: a prac cal approach to hospital management. Extreme Physiology and Medicine. 3:7 5. Gross, E.A. & Moore, J.C. (2012). Using thromboly cs in frostbite injury. Journal of Emergencies, Trauma, and Shock. 5 (3) Jul-Sep 6. Beim, J., Koehncke, N., Classen, D., Dosman, J. (). Out of the cold: management of hypothermia and frostbite. Canadian Medical Associa on Journal. 2003; 168 (3). 7. Winkenwerder, W. & Sawka, M.N. (2008). Disorders Due to Heat and Cold. In Goldman, L., &Auseillo, D. (Eds.), Cecil Medicine 23rd Ed. (pg 568-569). Philadelphia: Saunders Elsevier. 8. Carter, R., Garcia, A.M., Souhan, B.E. (2011). Pa ents presen ng with miliaria while wearing flame resistant clothing in high ambient temperatures: a case series. Journal of Medical Case Reports. 5: 474. 9. NWS. (2015). Heat Index Chart. Accessed on 11 Apr 15. h p://www.srh.weather.gov/jetstream/downloads/hea ndex_rh_f_20x12.pdf 10. Wet Bulb Globe Temperature (WBGT). Accessed on 11 Apr 15. h p:// www.chrononhotonthologos.com/misc/hygromtr.htm