Environmental Medicine Or How to not let Mother Nature kill You Mahew Puderbaugh, DO Capt, USAF, MC, FS 88 MDG, WPAFB, OH Objecves • IdenIfy the different types of Heat Injuries and common treatments • IdenIfy the different types of Cold Injuries and common treatments • IdenIfy the importance and treatment of AlItude Injuries • Know preventave measures against the common vectors that transmit disease Overview • Cold Injuries • Heat Injuries • AlItude Injuries • Vector PrevenIon Cold Injuries • Localized – Chilblain – Trench foot – Frost nip/Frost Bite • Systemic – Hypothermia Windchill1 Chilblains/Pernio2,3 • Localized inflammaon secondary to cold – Dorsal aspect of digits common – Erosions, ulcers, blisters rare • Affects Young Women preferenIally • Treatment: – PrevenIon is key (maintaining core body temp, layering clothes) • DifferenIal: – Cryoglobulinemia – Raynaud Phenomenon – Chilblain Lupus Erythematous – CML – AnIphospolipid 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: – PrevenIon 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 – TradiIonally 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/demenIa – Trauma/Homelessness • Treatment – Old: only rewarming and prevenon of infecon – New: TPA Stages of Frostbite Level 5 Treatment of Frostbite TPA and Frostbite4 Hypothermia6 • Loss of ability to sustain core body temperature • Classificaon: – 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 • PrevenIon! • 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 (Acve): 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: acIve external rewarming of trunk (prevent aerdrop) • 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 ExhausIon – 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, potenIal risk? • Treatment: – Wash with soap and water – Hypoallergenic loIon – Chlorhexidine loIon, salicylate 1%, emycin cream are also opIons – Removal of potenIal irritants – Takes a week or longer to clear up Mild Heat Illnesses • Heat Cramps – Post-exerIon secondary to electrolyte loss – Tx: Cool down, electrolyte replacement – Don’t confuse for exerIonal sickling • Heat Edema – Typically affects elderly, non-acclimazed – Tx: elevaon of extremiIes, hydraon, compression stockings • No Diurecs • Heat Syncope – Temporary circulatory insufficiency secondary to pooling of blood in peripheral veins – Tx: hydraon, counseling, r/o of other diseases Severe Sunburn • Damage to skin secondary to UV radiaon – Natural – ArIfical (tanning beds, phototherapy devices) • Prevalence: 34% in US • Risk: – Highest at noon – Cloud cover offers minor protecIon – AlItude increases risk – ReflecIon from snow (90%), sand (15-30%), and water (5-20%) also increases risk • Tx: – Aloe-vera/calamine – NSAIDS (oral or topical) – Topical AnImicrobials PRN Chronic Damage • Darker skin types have slightly more protecIon • Increased risk for melanoma and BCC • AcInic keratosis – Occasionally progress to SCC • Chronic Acnic DermaIs – Typically men over 60 What Sunscreen to Recommend • Recent FDA changes to labeling – SPF does not effecIvely measure protecIon from UVA • Broad Spectrum – Protects from both UVA/UVB – Ranges from 15-50+ – Water Resistant: SPF maintained aer 40 min of water acIvity – Very Water Resistant: SPF maintained aer 80 min • For most people: – Broad Spectrum – > 30 SPF, 1oz per total body applicaon – Apply 15-30 min before exposure, reapply q2h Examples (not endorsements) • Use 1 oz at a me • Reapply frequently (q2h) • Reapply aer water exposure PrevenIon • Tanning beds do not reduce risk of sunburn! • ProtecIve Clothing: – Broad brim hats – Long sleeves – Fabric: dark- colored, thick, Ightly woven Heat ExhausIon • Temperature is < 40°C – Clinical syndrome of volume loss – Water and salt loss – Replacement is subopImal in volume/ solute • Symptoms: – Malaise, fague, headache, – N/V, cramps, Diaphoresis – No alteraon in mental status • Signs: – Possible elevaon of hepac transaminases • Treatment: – IV fluids--aenIon to rate of sodium correcon – Cool Down quickly Heat Stroke • Core Body Temp >40°C (but not always) – Body has lost ability to thermoregulate • Symptoms: – + CNS dysfuncIon • 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 • PrevenIon – Acclimazaon (10-14 days) – Rest 1 week before return to acIvity AlItude Illness • Acute Mountain Syndrome • High AlItude Pulmonary Edema • High AlItude Cerebral Edema • Decompression Sickness Acute Mountain Syndrome • Symptoms: – Headache PLUS – Fague – Weakness – Dizzy/Lightheaded – Nausea/VomiIng – Anorexia – Sleep disturbance • Treatment: – Get down – Acetazolamide HAPE/HACE • HAPE – Symptoms –Fague, weakness, dyspnea, decreased exercise tolerance, delayed recovery from exerIon – Signs –Tachypnea, tachycardia, cough, frothy sputum, cyanosis, rales, decreased SaO2, patchy infiltrates – Occurs 2-4 days, >2500 m (8,200 o) • 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, CuIs Marmorta • Causes: – Ascent from 33o (10m) – Exposure to >18K o (5490m) – Flying aer diving – 12-48h surface interval depending on dive – DCS seen at 4,500o cabin alItude 3hr post-dive • Treatment : – 100% O2, aviator mask/NRBM – chamber ride Vector Borne Diseases • MulIple Diseases • MulIple Vectors – Mosquitos – Ticks – Flies – Kissing Bugs – Bats – Rodents Vectors • PrevenIon is Key when it comes to Vector Disease! Vectors • Know where you are going • Know the Risks: – Travax – State Dept – CIA Factbook – Naonal Center for Medical Intelligence • PrevenIon is always best! Summary • IdenIfy the different types of Heat Injuries and common treatments • IdenIfy the different types of Cold Injuries and common treatments • IdenIfy the importance and treatment of AlItude Injuries • Know preventave measures against the common vectors that transmit disease References 1. NOAA (2015). NWS Windchill Chart. Accessed on 11 Apr 15. h8p://www.nws.noaa.gov/om/winter/windchill.shtml 2. Derm101 (2015). Chilblains/Pernio. Accessed on 11 Apr 15. h8p://www.derm101.com/therapeuIc/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 pracIcal approach to hospital management. Extreme Physiology and Medicine. 3:7 5. Gross, E.A. & Moore, J.C. (2012). Using thrombolyIcs 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 AssociaCon 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). Paents presenIng 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. h8p://www.srh.weather.gov/jetstream/downloads/heandex_rh_f_20x12.pdf 10. Wet Bulb Globe Temperature (WBGT). Accessed on 11 Apr 15. h8p:// www.chrononhotonthologos.com/misc/hygromtr.htm .