A Song of Ice and Fire

A Song of Ice and Fire

As the year comes to an end, the holidays approach and, for lots of people, it means traveling to different places around the world. For those who live in the southern hemisphere, like me, the summer comes with al power, with temperatures as high as 35°C (95°F) or 40°C (104°F). For those who live in the northern hemisphere, “the winter is coming” and bring with him temperatures below 0°C (32°F) in some places. With these temperature extremes, we have some conditions to have in mind when working in the ED. How to treat a homeless patient who has slept on the streets on a freezing night? And how about an elderly person who lay on the beach sand under a blazing sun?

Hyperthermia

What is hyperthermia?

By definition, hyperthermia is a condition when there is a failure of the body’s thermoregulatory mechanisms to handle extrinsic and intrinsic heat. It’s common to see the expression “Heat-related Illness” to describe the conditions associated to the exposure to environmental heat.

Physiology

The heat-related illness (HRI) develops following a progressive pattern, divided in 3 phases [1].

  • ACUTE PHASE: 
    • Activation of inflammatory mediators, especially in the blood vessels; 
    • Gastrointestinal tract hypoperfusion, leading to bacterial translocation
    • Respiratory alkalosis due to hyperventilation
  • ENZYMATIC PHASE:
    • Coagulopathy, leading to a hypercoagulability state 
    • Endothelial injury and microvascular thrombosis 
    • All of this leading to disseminated intravascular coagulation (DIC)
  • LATE PHASE:
    • Liver dysfunction secondary to DIC
    • Kidney failure due to dehydration and hypotension
    • CNS lesions leading to cerebral edema and hemorrhage 
    • Cardiovascular dysfunction, worsening hypotension and causing vasoconstriction

Risk Factors

  • Extremes of age
  • Obesity
  • Elevated humidity rate
  • Lack of acclimatization and/or fitness
  • Ambient temperature
  • Dehydration
  • Cardiovascular disease
  • Drugs/medication (i.e alcohol, diuretics, amphetamines)

Categories of heat illness

  • Minor Heat Illness:  
    • Heat cramps: Intermittent muscle cramps likely related to salt deficiency and muscular fatigue, although the exact mechanism is not well known.
    • Heat Edema: Swelling of the feet and ankles typically in non-acclimatized people
    • Heat Syncope: Similar to orthostatic hypotension, caused by the physiologic response to the heat: volume depletion, peripheral vasodilatation and a reduced vasomotor tonus. More common in elderly people.
    • Prickly Heat: cutaneous rash caused by pores and sweat gland obstruction
  • Heat Exhaustion:
    • Occurs with a moderate elevation in the body core temperature (<40°C or 104°F) – RECTAL temperature is the most reliable method (even though is a level C evidence)
    • Usually accompanied by symptoms related to conditions described in the Minor Heat Illness and other nonspecific symptoms like nausea/vomiting, weakness and headache
    • DOES NOT PRESENT WITH ALTERED MENTAL STATUS
  • Heat Stroke:
    • Body temperature above 40° (104°F) WITH ALTERED MENTAL STATUS
    • Target organ damage
    • Usually dry and pale skin, however athletes can present with warm and wet skin

Management

  • Primary, we need to proceed with the basic measures: secure airway, monitorize and place IV fluids in order to maintain a mean arterial blood pressure > 60 mmHg [2].
  • The second step is to perform a rapid cooling, targeting a temperature <39°C (102°F) in the first 30 minutes. After reaching this goal, the active cooling should be stopped in order to avoid overshoot hypothermia
    • Cold water immersion is the best method available (level C evidence) [3].
      • Treat shivering with benzodiazepines if needed (avoiding extra heat generation)
    • DO NOT USE ANTIPYRETICS, they are not effective in this scenario [4].

Disposition

  • Patients with heat stroke should be admitted to a ICU to monitoring organ dysfunction, electrolytes disturbances and rebound hypothermia.
  • Young and otherwise healthy patients with heat exhaustion can be discharged home 
  • Be aware for the risk of recurrent hyperthermia when considering discharge a patient (returning to the same ambient)

Hypothermia

What is hypothermia?

  • Condition in which the body loses heat at a higher rate than its capacity in maintain the core temperature or elevate the heat production
  • Clinically defined as unintentional decrease of body temperature below 35°C (95°F)
  • In other settings, we can talk about “secondary hypothermia”, when the patient has an impaired thermoregulation due to a clinical condition such as hypothyroidism, ketoacidosis, malnutrition etc – In this article we will focus on accidental hypothermia, related to environmental exposure

Physiology

  • Initially, the metabolic rate increases, peripheral blood flow is shunted towards vital structures, and shivering initiates to increase heat production
  • If these compensations are not enough, the body temperature continues to drop, with the CNS being affected when it reaches 35°C (95°F). 
  • Cardiovascular: initial increase in heart rate and blood pressure; however, as core temperature declines, progressive bradycardia and hypotension occurs. In more severe hypothermia, myocardial irritability increases, leading to a high risk of arrhythmias.
  • Oxygen consumption: At a temperature of 28°C (82°F), the oxygen consumption is decreased by 50%, leading to a protective effect in CNS and other vital organs – but just if it develops before asphyxia (there are several studies trying to better understand the role of hypothermia as a protective measure in cardiac arrest) [5].

Risk Factors

  • Fatigue
  • Sleep deprivation
  • Rain, wind and water immersion
  • Burn
  • Extremes of age
  • Trauma
  • Alcohol
  • Hypoglycemia
  • Hypothyroidism
  • Hyperthermia treatment (rapid cooling)

Classification

Stage 1: Mild Hypothermia

  • Core temperature: 32 – 35°C (90 – 95°F)
  • Initially presenting with tachycardia, hypertension, shivering and vasoconstriction
  • Gradually develops ataxia, poor judgement, amnesia, apathy, dysarthria

Stage 2: Moderate Hypothermia

  • Core temperature 28 – 32°C (82 – 90°F)
  • Loss of shivering, lethargy, mydriasis, hyporeflexia, alterations in cardiac rhythm (Osborne J waves on EKG)

Stage 3: Severe Hypothermia

  • Core temperature: 24 – 28°C (75 – 82°F)
  • Hypoventilation, ventricular fibrillation, acid-basic disturbances, anesthesia, pulmonary edema 

Stage 4: Profound Hypothermia

  • Core temperature: below 24°C (75°F)
  • Oliguria, fixed pupils, asystole, apnea, coma 
  • Curiosity: 13,7°C (56,7°F) is the lowest temperature registered at which CPR was performed with satisfactory results [6].

Management

  • The first thing we need to do is to stop the cooling process 
    • Remove the environmental factor (take the patient out of the street, take off wet clothes etc.)
    • Try stop heat loss, putting up barriers like warm clothes, blankets, sleep bags, etc
  • Second step, we should identify the degree of hypothermia to guide our approach:
    • For Mild hypothermia, besides the strategies described before, we need to offer calories (food and warm drinks), monitoring for at least 30 minutes and warm the trunk
    •  [F]or Moderate hypothermia, we also need to keep the patient laid down and still, start volume reposition with warm fluids (40 – 42°C/104 – 107°F), Avoid food and beverage.
    • For Severe hypothermia: All the above and check for pulse and breathing – of pulse/breathing is absent, START CPR. – Consider transferring to a facility where ECMO is available
      • ECMO is the best option for severely hypothermic patients without signs of life who do not respond to initial resuscitative efforts. It has been shown to improve neurologically intact survival (48% to 63% survival with ECMO, <37% without ECMO) [7]. 

 “Nobody is dead until warm and dead”

Patients with core temperatures of <28°C have decreased electroencephalographic activity and loss of brainstem and pupillary reflexes, all of which may mimic death. Because of that, the patient can not be considered “dead” until his body temperature reaches at least 32°C.

Some conditions allow us to presume death even in patients with body temperature below 32°C and no vital signs: obvious lethal injury (i.e. decapitation), frozen body, potassium > 12, avalanche victims with burial > 35min or airway packed with snow.

References and Further Reading

The primary reference for this article was the recently launched book: “Medicina em Áreas Remotas no Brasil” (Wilderness Medicine in Brazil): JULIANA R. M. SCHLAAD e SASCHA W. SCHLAAD, Medicina em Áreas Remotas no Brasil, 1ed, Barueri (SP), Manole, 2020

Other sources of information as numbered and referred in the text:

  1. Powers SK, Howley ET. Regulação de temperatura. In: Powers SK, Howley ET. Fisiologia do exercício: teoria e aplicação ao conhecimento e ao desempenho. 9ed. Barueri: Manole; 2017. p.261-281.
  2. Tran TP. Heat emergencies. In: Ma OJ, Cline DM, ed. Emergency medicine manual. 6th ed. McGraw-Hill, NY: 2004:564-565
  3. Becker J, Stewart L. Heat-related illness. Am Fam Physician. 2011;83(11):1325-1330
  4. Lipman GS, Eifling KP, Ellis MA, Gaudio FG, Otten EM, Grissom CK. Wilderness medical society practice guidelines for the prevention and treatment of heat-related illness: 2014 update. Wilderness Environ Med. 2014; 25:S55-S65
  5. Soar J, Perkins G, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation. 2010;81(10):1400-1433.
  6. M. Gilbert, R. Busund, A. Skagseth, Nilsen PÅ, J.P. Solbø Resuscitation from accidental hypothermia of 13.7 degrees C with circulatory arrest Lancet, 355 (2000), pp. 375-376
  7. Brown DJ et al. Accidental hypothermia. NEJM 2012; 367(20): 1930-1938. PMID: 23150960
Cite this article as: Arthur Martins, Brasil, "A Song of Ice and Fire," in International Emergency Medicine Education Project, December 25, 2019, https://iem-student.org/2019/12/25/a-song-of-ice-and-fire/, date accessed: July 12, 2020

Death on the Roads

Death on the Roads

Save the date:

Why? Because road victims will be remembered that day. Starting from 2005, The World Day of Remembrance for Road Traffic Victims is held on the third Sunday of November each year to remember those who died or were injured from road crashes (1).

Road traffic injuries kill more than 1.35 million people every year and they are the number one cause of death among 15–29-year-olds. There are also over 50 million people who are injured in non-fatal crashes every year. These also cause a real economic burden. Total cost of injuries is as high as 5% of GDP in some low- and middle-income countries and cost 3% of gross domestic product (2). It is also important to note that there has been no reduction in the number of road traffic deaths in any low-income country since 2013.

The proportion of population, road traffic deaths, and registered motor vehicles by country income, 2016 (Source: Global Status Report On Road Safety 2018, WHO)

Emergency care for injury has pivotal importance in improving the post-crash response. “Effective care of the injured requires a series of time-sensitive actions, beginning with the activation of the emergency care system, and continuing with care at the scene, transport, and facility-based emergency care” as outlined in detail in World Health Organization’s (WHO) Post-Crash Response Booklet.

As we know, the majority of deaths after road traffic injuries occur in the first hours following the accident. Interventions performed during these “golden hours” are considered to have the most significant impact on mortality and morbidity. Therefore, having an advanced emergency medical response system in order to make emergency care effective is highly essential for countries.

Various health components are used to assess the development of health systems by country. Where a country is placed in these parameters also shows the level of overall development of that country. WHO states that 93% of the world’s fatalities related to road injuries occur in low-income and middle-income countries, even though these countries have approximately 60% of the world’s vehicles. This statistic shows that road traffic injuries may be considered as one of the “barometer”s to assess the development of a country’s health system. If a country has a high rate of road traffic injuries, that may clearly demonstrate the country has deficiencies of health management as well as infrastructure, education and legal deficiencies.

WHO has a rather depressing page showing numbers of deaths related to road injuries. (Source: Death on the Roads, WHO, https://extranet.who.int/roadsafety/death-on-the-roads/ )

WHO is monitoring progress on road safety through global status reports. Its’ global status report on road safety 2018 presents information on road safety from 175 countries (3).

We have studied the statistics presented in the report and made two maps (All countries and High-income countries) illustrating the road accident death rate by country (per 100,000 population). You can view these works below (click on images to view full size).

References and Further Reading

  1. Official website of The World Day of Remembrance, https://worlddayofremembrance.org
  2. WHO. Road traffic injuries – https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries
  3. WHO. Global status report on road safety 2018 – https://www.who.int/violence_injury_prevention/road_safety_status/2018/en/
Cite this article as: Ibrahim Sarbay, Turkey, "Death on the Roads," in International Emergency Medicine Education Project, November 1, 2019, https://iem-student.org/2019/11/01/death-on-the-roads/, date accessed: July 12, 2020

ELECTRIC SHOCK; Injuries beyond what the eyes see.​

electric shock

Authors: Dr. Nour Saleh and Dr. Kilalo Mjema

Case presentation

A 53-years-old male, sustained burn wounds on both hands 40 minutes prior presentation to the ED

Primary survey

  • Airway: patent and protected.
  • Breathing: bilateral equal air entry
  • Circulation: warm extremities, capillary refill time is 1 second
    • Vitals on presentation
      • BP: 177/114mmHg
      • HR: 115
      • RR: 16
      • SPO2: 96% in room air
      • T: 36.4
  • Disability: alert and oriented, pupils 5mm bilateral equal light reaction, glucose: 7.3mmol
  • Exposure: holding his hands up in pain with some black discoloration

SAMPLE History

  • Sign and symptoms: pain, see pictures
  • Allergy: no known allergies
  • Medications: not on any medication
  • Past medical history: no known comorbid or any significant medical history
    Last meal: he ate about 2.5 hours prior presentation
  • Event: pain on both hands after sustaining burn injury forty minutes prior presentation to the ED while trying to connect two circuits that sparked causing burn wounds on his hands and felt a jolt of electricity.

No history of heartbeat awareness or any loss of consciousness

electrical injury
electrical injury

Interventions and key steps in management

  • Make sure ABCD is checked and there is no critical intervention needed
  • IV access and fluid resuscitation may be considered depending on the case
  • Analgesics: depends on the severity of pain. Fentanyl 50mcg IV stat can be necessary for many patients.
  • Informed consent for procedural sedation for the dressing of the wounds.
  • Sedation: during the dressing of wounds
  • Point-of-care investigations: ECG, Urine dipstick
  • Blood samples for some labs should be taken; Creatinine, CK, Myoglobin, Electrolytes, Calcium, and Troponin
  • Imaging: X-ray if there is a worry for associated fracture
  • Monitor: input of fluids and output of urine to watch for acute kidney injury, compartment syndrome and rhabdomyolysis
  • Do not forget tetanus immunization

Associated injuries

  • Cardiac arrhythmias

    Ventricular fibrillation is the most common. It occurs in 60% of patients with electrical current traveling from one hand to the other.

  • Renal - Rhabdomyolysis

    Massive tissue necrosis may result in acute kidney injury. Labs to check includes; Creatinine, Blood Urea Nitrogen, Total CK, myoglobin.

  • Neurological

    Damage to both central and peripheral nervous systems can occur. The presentation may include weakness or paralysis, respiratory depression, autonomic dysfunction, memory disturbances, loss of consciousness.

  • Skin

    Degree of injury cannot determine the extent of internal damage especially with low voltage injuries. Minor surface burns may co-exist with massive muscle coagulation and necrosis.

  • Musculoskeletal

    Bones have the highest resistance of any body tissues resulting in the greatest amount of heat when exposed to an electrical current. Results in surrounding tissue damage and potentially may lead to periosteal burns, destruction of bone matrix and osteonecrosis.

  • Vascular / Coagulation system

    Due to electrical coagulation of small blood vessels or acute compartment syndrome.

  • Internal organs

    The internal organ injury is not common but when it happens may result serious problems such as bowel perforations leading to polymicrobial infection, sepsis, and death.

Disposition

Admission and discharge decisions of burn patients depend on the patient’s current situation, burn percentage according to body surface area, location of the burn, and complications of burn. Low voltage electrocutions, if they are asymptomatic with normal physical examinations, can be discharged. Discharge precautions regarding burn care and complications should be clearly explained to the patient and relatives.

Further Reading

Cite this article as: Kilalo Mjema, "ELECTRIC SHOCK; Injuries beyond what the eyes see.​," in International Emergency Medicine Education Project, October 2, 2019, https://iem-student.org/2019/10/02/electric-shock-injuries-beyond-what-the-eyes-see-%e2%80%8b/, date accessed: July 12, 2020

A Farmer’s Dilemma

Farmer's Dilemma

Case Presentation

It was a rainy night preceding my morning shift as a year 3 EM resident at one of our training centers in Abu Dhabi. The paramedics barged in with an agitated patient, who was found soaking wet in a farm field.

According to brief history that we got from the paramedics, the patient works at a farm and his boss found him collapsed, cold to touch and confused in the early morning hours. Paramedics also reported a confused, hypothermic, and tachycardic patient. They brought him directly to the ED, with no accompanying friends or family.

As we proceeded to resuscitate the patient, we noted that his initial vital signs did confirm hypothermia of 32 Celsius measured rectally, tachycardia, hypertension, and normal O2 saturation. We hooked him to the monitor, removed his wet clothing, gained IV access, started him on warm IV fluids, and covered him with blankets and a warming Bair Hugger (a warming blanket system).

Physical Exam

The patient was confused, agitated and uttering incomprehensive words, with a GCS of 11 (E3 V3 M5). I proceeded to examine him looking for more clues of why he was laying semiconscious under the rain all night. Systematic physical examination revealed pinpoint pupils, frothing and excessive salivations. Furthermore, diffuse mild crackles were noted on chest auscultation, and he was tachycardic with a regular rate and rhythm. Remaining physical exam was unremarkable, and a complete neurological exam was challenging.

Differential Diagnosis and Workup

Thinking of a broad differential diagnosis of altered mental status, systematic consideration of all possible etiologies similar to our patient presentation was reviewed. We have considered metabolic derangements, head trauma, CNS causes such as seizures and post-ictal status, infectious causes such as pneumonia or meningitis, and toxicologic causes, such as alcohol withdrawal, or medications overdose.

You may find useful this mnemonic for altered mental status!

ALTERED MENTAL STSTUS

Further management plan included giving him benzodiazepines for the agitation and possible post-ictal status. We collected basic blood work and proceeded for a head CT to rule out traumatic or atraumatic intracranial pathologies. Blood workup was inclusive of an alcohol level, Aspirin, Acetaminophen level, and a urine toxicology screen.

As the patient returned from the CT, he apparently had passed the copious amount of loose stools, that smelled surprisingly like garlic that studded the ED with its smell.

The head CT was normal, and most of his blood workup came back unremarkable. But, he remained confused and agitated as the benzodiazepines were wearing off and despite all the warming measures. ECG showed only sinus tachycardia, and a chest X-Ray was unremarkable.

smells like garlic!

What do you think? What are the causes for this?

agents smells like garlic

phosphorus, tellurium, inorganic arsenicals and arsine gas, organophosphates, selenium, thallium, dimethyl sulfoxide
Learn More

The garlic smell did give us a lead though, we thought further of possible toxic agents that may give such a smell, along with a consistent similar clinical picture.

Case Management and Disposition

Collecting our clues once more, we had pinpoint pupils, frothing, salivation, wet lungs, vomiting and loose motions. Patient’s collective symptoms and signs indicated a Cholinergic Toxidrome, possibly due to Organophosphates ingestion.

The patient was already decontaminated with removal of all his clothes. All healthcare providers were equipped with personal protective equipment.

This was confirmed an hour later when his farm owner showed up with a Pesticides Bottle that he found near him in the early morning hours before calling an ambulance. Pesticide is shown in Figure. The content of the bottle is consistent with Organophosphates Toxicity, and hence his Cholinergic Toxidrome.

Pesticide Bottle Found Next To The Patient.
Pesticide Bottle Found Next To The Patient.

He was started on Atropine, and Pralidoxime, assessed and admitted to the ICU with arranged psychiatric consult to assess his suicidal ideations once he stabilizes.

Critical Thinking and Take-home Tips

A collection of symptoms and physical signs caused by a certain toxic agent.

Cholinergic
Anticholinergic
Sedative/Hypnotic
Sympatholytic
Sympathomimetics

Cholinergic toxicity represents a cholinesterase inhibitor poisoning. It results from the accumulation of excessive levels of acetylcholine in synapses. Clinical picture resulting from the Acetylcholine build up depends on the type of receptors that it stimulates and where is it found in the body. It can stimulate the nicotinic and muscarinic receptors. The balance of these stimulations reflects such clinical presentations.

Think of the symptoms that can be caused depending on the type of receptors affected by the buildup of acetylcholine.

Muscarinic Receptors – SLUDGE(M)

  • Salivation
  • Lacrimation
  • Urination
  • Diarrhea
  • Gastrointestinal pain
  • Emesis
  • Miosis

Nicotinic Receptors (NMJ) – MTWThF

  • Mydriasis/Muscle cramps
  • Tachycardia
  • Weakness
  • Twitching
  • Hypertension
  • Hyperglycemia
  • Fasciculations

These are called the Killers B’s which consist of Bradycardia, Bronchorrhea and Bronchospasm.

Decontamination should always be considered first in all cases with possible hazardous exposure from the patient and his environment to all health care providers in contact with him. All caregivers should wear appropriate personal protective equipment’s and make sure to remove all clothing and possible objects with the suspected contaminant.

Supportive care is a cornerstone to all unstable patients, make sure that they are monitored, with proper IV access and supplemental oxygen as needed.

Furthermore, airway management is lifesaving in similar patients, as bronchorrhea is one of the killer B’s and can lead to high fatality.

Antidotes such as Atropine and Pralidoxime in Cholinergic toxicity are paramount, as they help reverse the etiology, and prevent further worsening of the toxicity.

Make sure that such patients are admitted under needed specialty care with proper observation and reassessment for the patient.

Consult a toxicologist if feasible in your center to provide you with further management details and interventions that can help your patients better.

Conclusion

Organophosphates can be found in pesticides, chemical weapons such as nerve gases, and few medications as well such as neostigmine or edrophonium. They are highly lipid soluble making them easily absorbed via breathing and skin contact as well. Encountering similar patients, it is quite important to always be systematic in your approach, resuscitate your patient first, and make sure to use your history taking as feasible and physical examination to collect all the clues needed to narrow down your differentials and find the most appropriate treatment needed for your patient.

References and Further Reading

  1. Organophosphate toxicity on WikEM: https://www.wikem.org/wiki/Organophosphate_toxicity
  2. Das RN, Parajuli S. Cypermethrin poisoning and anti-cholinergic medication- a case report. Internet J Med Update. 2006;1:42–4.
  3. Aggarwal, Praveen et al. “Suicidal poisoning with cypermethrin: A clinical dilemma in the emergency department.” Journal of emergencies, trauma, and shock vol. 8,2 (2015): 123-5. doi:10.4103/0974-2700.145424
  4. Lekei EE, Ngowi AV, London L. Farmers’ knowledge, practices and injuries associated with pesticide exposure in rural farming villages in Tanzania. BMC Public Health. 2014;14:389. Published 2014 Apr 23. doi:10.1186/1471-2458-14-389

Suggested Chapters and Posts in iEM

Cite this article as: Shaza Karrar, UAE, "A Farmer’s Dilemma," in International Emergency Medicine Education Project, July 19, 2019, https://iem-student.org/2019/07/19/a-farmers-dilemma/, date accessed: July 12, 2020

Adventures on the Annapurna Circuit

For this blog entry, I want to share two issues I encountered while traveling in Nepal, just shy of my graduation from medical school: acute mountain sickness (AMS) and responding to a wilderness medicine incident as a medical trainee.

There is nothing more glorious

There is nothing more glorious than the period just after finishing medical school and before residency! For me, the highlight was being able to hike in Nepal. With the long travel time from Canada, and the multi-day itineraries most hikes necessitate, the post-grad period seemed like the ideal opportunity to make my dream of visiting the Himalayas come true.

Courtesy of Helene Morakis
Courtesy of Helene Morakis

I wrote my medical licensing exam, hopped on a flight and got ready to soak up the change of pace. While traveling, I found time to relax, (tried my best to) practice mindfulness and experienced the incredible kindness of Nepali people. Traveling was the perfect recharge that now has me geared up and excited for residency.

Annapurna Circuit

A few weeks before leaving for my travels, I began researching the Annapurna Circuit (APC). Having grown up at a staggering 240m above sea level in the Canadian prairies, I felt threatened by the Thorong La pass, which at 5416m is the highest part of the trek. My highest previous experience at altitude was 4200 meters, where I (unfortunately) developed Acute Mountain Sickness (AMS). My history of having AMS and following a typical itinerary for the APC put me at moderate risk for AMS(1). I decided to heed the Wilderness Medicine Society’s recommendation to take acetazolamide 125mg every 12 hours as prophylaxis(1).

Table reproduced from Luks, A. M. et. al 2019

While on the trek, I overheard many myths about AMS and sensed a general reluctance to take acetazolamide as prophylaxis(2). Himalayan Rescue Association does free daily teaching about AMS on the APC in Manang and on the Everest Base Camp trek as well(3). As we moved to higher altitudes, many guest houses and Annapurna Conservation Area Project outposts had accurate information about AMS and its consequences (High Altitude Pulmonary Edema and High Altitude Cerebral Edema). Surprisingly, despite this teaching and the availability of acetazolamide on the trail for purchase, there are still hikers that routinely require evacuation due to AMS, some by helicopter.

On the day before crossing the Thorong La Pass, I stopped for lunch with some trekking mates at Thorong Phedi (4538m). A few minutes passed before someone came into the guesthouse, visibly worried, requesting help from a doctor. It took me a few seconds (and my friends practically lifting me off my seat) to register that I could help! I was thankful to be hiking with an experienced nurse and we went to see the hiker together.

We were asked to see a fit hiker in his 60’s whose foot had been the victim of a rockslide. I clarified my training as a fourth-year medical student before asking details about the mechanism of injury and his past medical history. The hiker and his family were concerned and asked me to “rule out” a fracture. With positive Ottawa Ankle Rules findings, I wished for an X-Ray machine to rule out a clinically significant fracture(4). Keeping in mind there was no road access – the nearest road before the camp was in Manang (3500m, 15km away) or in Muktinath (3800m, 16km away) after the pass – the only ways out were by donkey or helicopter.

From a wilderness medicine standpoint, the injury was by all measures considered stable and the patient did not require an evacuation [reproduced from Isaac & Johnson 2013](5):

  • No deformity or instability on exam

  • No sense of instability reported by patient

  • Able to move and weight bear after accident

  • Distal circulation, sensation, movement (CSM) intact

  • Slow onset of swelling

  • Pain proportional to apparent injury

After a discussion with the patient, we decided that treating the injury as “stable” was reasonable and accepted the risk of delaying healing of a potential fracture. I recommended 24 hours of rest, ice (which kept the patient’s family busy fetching snow!), and elevation. I gave them ibuprofen to be administered on a regular schedule and instructed them to monitor CSM and plan an evacuation if there were any signs of impairment. I told the patient to continue the hike the following day if the pain did not increase with activity and to obtain medical follow up once they had returned to the city.

In hindsight, I recognized that I should have documented the encounter. I had written down the dosing of ibuprofen for the family, but I did not write a detailed SOAP (subjective, objective, assessment and plan) note. Properly documenting wilderness medicine encounters was a skill I learned in Advanced Wilderness Life Support. When we met the patient, he was generally well other than his foot injury. What if the patient’s condition worsened? What if the family forgot the plan in the stress of the situation?

I also found myself wondering about this patient long after I had left them. Reflecting upon this, I recognized that it is easier to “discharge” someone from an urban Canadian ED, where I have had most of my clinical experience because I know they can access good care if things change. The huge potential on the trail for loss to follow up made documentation much more vital in this case.

Later on, I pondered about the potential legal ramifications of helping this hiker. In Ontario, Good Samaritan laws protect health care professionals who provide first aid(6). From my understanding, there are no similar laws in Nepal, and there have been calls to define the rights and duties of those who witness or are requested to aid with an injury in the country(7).

In Nepal, I had a much-needed change of pace from medical school and plenty of time for reflection. I was inspired to see many organizations work together to educate guides, locals and hikers about AMS and hope to spend some time volunteering at the Himalayan Rescue Association in the future. Even after wilderness medicine training, being asked to provide first aid on the trail as a soon to be medical graduate caught me by surprise. I was happy to help and be able to have an approach to the patient in a low resource setting – and now recognize the importance of documentation.

I would like to hear your comments on this article: any experiences dealing with AMS, tips and tricks for musculoskeletal injuries in the wilderness setting, advice for navigating giving medical treatment outside of a hospital as a trainee or anything you would have done differently.

Courtesy of Helene Morakis

References

  1. Luks, A. M., Auerbach, P. S., Freer, L., Grissom, C. K., Keyes, L. E., McIntosh, S. E., … Hackett, P. H. (2019). Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update. Wilderness & Environmental Medicine. https://doi.org/10.1016/j.wem.2019.04.006
  2. Kilner, T., & Mukerji, S. (2010). Acute mountain sickness prophylaxis: Knowledge, attitudes, & behaviours in the Everest region of Nepal. Travel Medicine and Infectious Disease, 8(6), 395–400. https://doi.org/https://doi.org/10.1016/j.tmaid.2010.09.004
  3. Himalayan Rescue Association. (2019). [online] Available at https://himalayanrescue.org.np/ [Accessed 30 Jun. 2019].
  4. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992; 21:384–90.
  5. Isaac, J. E., & Johnson, D. E. (2013). Chapter 13: Musculoskeletal Injury. In Wilderness and Rescue Medicine (pp. 84–85). Burlington, MA: Jones & Bartlett Learning.
  6. Good Samaritan Act, Government of Ontario (2001). Retrieved from the Ontario e-Laws website: https://www.ontario.ca/laws/statute/01g02
  7. Pandey, S. (2014). Good Samaritans. [online] The Kathmandu Post. Available at: https://kathmandupost.ekantipur.com/news/2014-07-13/good-samaritans.html [Accessed 30 Jun. 2019].

Further Reading

Cite this article as: Helene Morakis, Canada, "Adventures on the Annapurna Circuit," in International Emergency Medicine Education Project, July 12, 2019, https://iem-student.org/2019/07/12/adventures-on-the-annapurna-circuit/, date accessed: July 12, 2020

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Heat Illness chapter written by Abdulaziz Al Mulaik from KSA is just uploaded to the Website!

A new chapter is added – Drowning

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Drowning chapter written by Ana Spehonja from Slovenia is just uploaded to the Website!

Electrical injury

In case you didn’t encounter electrical injury today!

685.1 - electrical injury entry

The above picture shows entry wounds of electrical injury. One of the important hints is DO NOT DELAY TO TAKE OFF RINGS for any hand injury!

684.4 - electrical injury exit

The above picture shows exit wounds of the same patient. 

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

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684.1 - electrical injury - rhabdomyolysis

In case you didn’t encounter a construction worker who presented with high voltage electrical injury today!

683.4 - electrical burn entry

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

From Experts To Our Students! – Burn Injuries

rahul goswami - burns

Burns chapter written by Rahul Goswami from Singapore is just uploaded to the Website!