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  Asymptomatic - CXR, consider labs (electrolytes, blood count) - Evaluate primary vs secondary drowning - Evaluate for traumatic injury mit to monitored bed Discharge home Figure 64-2. Drown ing incidents diag nostic algorithm. CXR, chest x-ray; ICU, intensive care unit. DISPOSITION Patient condition will largely determine disposition. Poor prognostic factors include: • Submersion for > 10 minutes • > 10 minutes before initiation of basic life support measures in an apneic/pulseless patient • >25 minutes of pulselessness • Initial temperature <33°C (92°F) • Initial Glasgow score <5 • Need for cardiopulmonary resuscitation in the ED • Submersion in water colder than l 0°C (50°F) • Initial arterial blood gas pH <7.1 � Admission Admission is indicated for any symptomatic patient. Those who are intubated, have persistently altered mental status, are hypothermic, or require high-flow oxygen should be admitted to an intensive care unit. Cardiac monitoring is indicated for

  Hallam MJ, Cubison T, Dheansa B, I mray C. Managing frostbite. BM]. 201 0;341:1 151. Ulrich AS, Rathlev NK. Hypothermia and localized c old injuries. Emerg Med Clin North Am. 2004;22:28 1. Heat-Related Illness Natalie Radford, MD Key Points • Always consider secondary causes of hyperthermia. Heat exhaustion and heat stroke should be diagnoses of exclusion. • Do not fluid overload elderly patients while rehydrating them in the emergency department (ED). Remember that their fluid and electrolyte deficits developed over INTRODUCTION Heat exhaustion and heat stroke are on a continuum of disease severity. Heat exhaustion occurs when the body can no longer dissipate heat adequately, resulting in hyperthermia. Heat stroke is the result of complete thermoregulatory dysfunction. Classic heat injury occurs in the elderly or ill with prolonged exposure to high environmental temperatures. Physical exertion is not required. Elevated temperatures and high humidity overwhelm the body's normal c

   Do not use water warmed above 42°C to avoid superimposed thermal injury. Never initiate rewarming in the prehospital setting if there is any potential for refreezing, as this can worsen tissue injury. A rewarming period of between 15 and 60 minutes is adequate for most patients. Use the appearance of the affected tissues to guide the duration of therapy. Appropriately rewarmed tissue should appear erythematous and pliable. Encourage active movement of the affected extremity to stimulate increased circulation. Rewarming can be exceptionally painful, and parental opioids are frequently required. Numerous adjunctive therapies have been proposed, although the evidence supporting their use is lacking ( Table 62- 1). It may take many weeks for the full extent of the patient's injuries to declare. That said, certain early findings do suggest better or worse outcomes. Findings associated with a better prognosis include the rapid re-establishment of normal skin temperature and sensation

  CHAPTER 63 ( 104°F). Patients complain of nonspecific symptoms and signs including weakness, dizziness, fatigue, nausea, vomiting, headache, myalgias, tachycardia, tachypnea, hypotension, and diaphoresis. By definition, mental status remains normal. Heat stroke patients present with altered mental status (AMS) ranging from mild confusion to coma. Body temperature is elevated above 40°C ( 104°F), and they may or may not be sweating. Patients can exhibit a wide range of neurologic symptoms and signs, including ataxia, seizures, and hemiple - gia. Multiorgan system failure consisting of hepatic, renal, and cardiac impairment may also be present in severe cases . ..... History Important factors to address in the history include a full description of the circumstances surrounding the heat exposure. Has the patient been in a non-air-conditioned apartment in the summer for several days, or has the patient been working outside while there is an elevated heat index? Past medical history shoul

  cardial instability and/or cardiac arrest require active core rewarming. Available modalities include warmed isotonic saline (40°C) lavage of the stomach (only if intubated), HYPOTHERMIA n�����:�--------:--'�� ......._.,.___,f-_.; f Figure 61-1. ECG demonstrating Osborn J waves (arrow) in a hypothermic patient. Shivering mechanisms intact, no significant comorbidities Impaired thermogenesis or significant comorbid ill ness rewarming Admission to telemetry bed .6. Figure 61-2. Hypothermia diag nostic algorithm. CHAPTER 61 bladder, and colon. Peritoneal and pleural irrigation can also be performed after the insertion of percutaneous catheters. Emergent thoracotomy with internal cardiac massage and mediastinal irrigation with warmed saline is a very invasive technique, but has been used successfully in severely hypothermic patients with prolonged cardiac arrest. When available, extracorporeal rewarming with cardiopulmonary bypass remains the most rapid way (>9°C/hr) to rewarm a p

  tive medications, and external conditions such as high altitude exposure. Mechanical risk factors compose the final category and are the most easily correctable. Common examples include constrictive clothing and jewelry, prolonged contact with heat conductive materials, and immobility. Of the 3 types of NFCI, frostnip is the least severe. It typically affects the distal extremities after prolonged exposure to cold but nonfreezing temperatures. Ice crystal formation and profound vasoconstriction are common in the superficial tissues, and patients frequently complain of a dull throbbing pain during rewarming. Essentially a precursor to frostbite, overt tissue destruction is lacking. Chilblains (pernio) involve the formation of inflammatory skin lesions after repeated intermittent exposure to a nonfreezing but cold and wet environment. Although chilblains can affect any area of the body, the face, dorsal surfaces of the hands and feet, and pretibial tissues are the most commonly involve