Environmental Medicine

Environmental Medicine Or How to not let Mother Nature kill You Ma8hew Puderbaugh, DO Capt, USAF, MC, FS 88 MDG, WPAFB, OH ObjecIves •  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 preventaIve measures against the common vectors that transmit disease Overview • 
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Cold Injuries Heat Injuries AlItude Injuries Vector PrevenIon Cold Injuries •  Localized –  Chilblain –  Trench foot –  Frost nip/Frost Bite •  Systemic –  Hypothermia 1 Windchill
2,3 Chilblains/Pernio
•  Localized inflammaIon 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: – 
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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 4,5 Frostbite
•  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 prevenIon of infecIon –  New: TPA Stages of Frostbite Level 5 Treatment of Frostbite 4 TPA and Frostbite
6 Hypothermia
•  Loss of ability to sustain core body temperature •  ClassificaIon: –  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) 6 Hypothermia Treatment
•  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 (AcIve): 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) 6 Hypothermia Treatment
•  Mild Hypothermia: passive external rewarming typically sufficient •  Moderate Hypothermia: acIve external rewarming of trunk (prevent aoerdrop) •  Severe/Worse Hypothermia: invasive techniques –  Can try CP bypass and Hemodialysis in severe cases 7 Heat Injuries
•  Mild Heat Illnesses –  Miliaria rubra (heat rash) –  Heat syncope –  Heat cramps •  Severe Heat Illnesses –  Severe Sunburn –  Heat ExhausIon –  Heat Stroke 10 Wet Bulb Globe Thermometer
•  Consists of 3 Thermometers: –  Black Globe (G) –  Dry Globe (A) –  Wet Globe (W) –  0.2G + 0.1A + 0.7W 8 Miliaria Rubra/Prickly Heat
•  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-­‐acclimaIzed –  Tx: elevaIon of extremiIes, hydraIon, compression stockings •  No DiureIcs •  Heat Syncope –  Temporary circulatory insufficiency secondary to pooling of blood in peripheral veins –  Tx: hydraIon, counseling, r/o of other diseases Severe Sunburn •  Damage to skin secondary to UV radiaIon –  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 AcInic DermaIIs –  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 aoer 40 min of water acIvity –  Very Water Resistant: SPF maintained aoer 80 min •  For most people: –  Broad Spectrum –  > 30 SPF, 1oz per total body applicaIon –  Apply 15-­‐30 min before exposure, reapply q2h Examples (not endorsements) •  Use 1 oz at a Ime •  Reapply frequently (q2h) •  Reapply aoer 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, faIgue, headache, –  N/V, cramps, Diaphoresis –  No alteraIon in mental status •  Signs: –  Possible elevaIon of hepaIc transaminases •  Treatment: –  IV fluids-­‐-­‐a8enIon to rate of sodium correcIon –  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 –  AcclimaIzaIon (10-­‐14 days) –  Rest 1 week before return to acIvity AlItude Illness • 
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Acute Mountain Syndrome High AlItude Pulmonary Edema High AlItude Cerebral Edema Decompression Sickness Acute Mountain Syndrome •  Symptoms: –  Headache PLUS –  FaIgue –  Weakness –  Dizzy/Lightheaded –  Nausea/VomiIng –  Anorexia –  Sleep disturbance •  Treatment: –  Get down –  Acetazolamide HAPE/HACE •  HAPE –  Symptoms –FaIgue, 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 •  Tx: •  Basically worsening Acute Mountain Sickness –  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 aoer 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 –  NaIonal 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 preventaIve measures against the common vectors that transmit disease References 1. 
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NOAA (2015). NWS Windchill Chart. Accessed on 11 Apr 15. h8p://www.nws.noaa.gov/om/winter/windchill.shtml Derm101 (2015). Chilblains/Pernio. Accessed on 11 Apr 15. h8p://www.derm101.com/therapeuIc/perniochilblains/ Olin, J.W. (2008). Other Peripheral Vascular Diseases. In Goldman, L., & Ausiello, D. (Eds.), Cecil Medicine 23rd Ed. (pg 568-­‐569). Philadelphia: Saunders Elsevier. Handford, C. (2014). Frostbite: a pracIcal approach to hospital management. Extreme Physiology and Medicine. 3:7 Gross, E.A. & Moore, J.C. (2012). Using thrombolyIcs in frostbite injury. Journal of Emergencies, Trauma, and Shock. 5 (3) Jul-­‐Sep Beim, J., Koehncke, N., Classen, D., Dosman, J. (). Out of the cold: management of hypothermia and frostbite. Canadian Medical AssociaCon Journal. 2003; 168 (3). 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. Carter, R., Garcia, A.M., Souhan, B.E. (2011). PaIents presenIng with miliaria while wearing flame resistant clothing in high ambient temperatures: a case series. Journal of Medical Case Reports. 5: 474. NWS. (2015). Heat Index Chart. Accessed on 11 Apr 15. h8p://www.srh.weather.gov/jetstream/downloads/heaIndex_rh_f_20x12.pdf Wet Bulb Globe Temperature (WBGT). Accessed on 11 Apr 15. h8p://
www.chrononhotonthologos.com/misc/hygromtr.htm