Snake Bite Heat Emergency l l prehospital care
Snake Bite Heat Emergency 전남대학교 응급의학교실 허 탁
독사교상 차례 l l 독사교상의 역학 임상증상 prehospital care of snakebite ED care of snakebite
독사교상의 역학 ; 독액(Enzyme) l Hyaluronidase disrupting mucopolysaccharides -> rapid spread of venom l Phospholipase A 2 esteolytic effect on RBC membrane -> hemolysis promotes muscle necrosis l Thrombogenic Enzymes Promote formation of a weak fibrin clot -> activates plasmin
임상증상 독사교상의 증상 l The presence of one or more fang marks l Localized pain l Progressive edema extending from the bite site www. themegallery. com
임상증상 l 국소증상 상처부위 부종과 통증, 마비감, 수포, 국소의 출혈괴사 fang marks, pain, swelling/edema, echymosis, vesicle, bullae, tissue necrosis
임상증상 l 전신증상 시력 모호, 복시, 호흡곤란, 사지마비, 피하 반점 nausea/vomiting, diaphoresis, perioral numbness/tingling metallic taste in mouth, coagulation defect, shock l 합병증 compartment syndrome 봉와직염, 조직괴사, 파종성 혈관내응고, 급성쇼크, 뇌경색과 지주막하 출혈, 사망
임상증상 l 증상발현 - 뱀의 종류 및 크기, 교상 부위, 교상 시기, 교상 깊이 환자의 체격 등 - 독사에 물렸다고 하여 전부 독증상이 나타나는 것이 아 니고 30~50%에서는 독증상이 없음(8 -12시간 관찰) cause of death from snake bite 1. coagulation defect --> hemorrhage or multiple thrombi 2. increased capillary permeability --> hypotension 3. 1, 2에 의해 heart and kidney damage, massive pulmonary edema and death l
Snake Bite in South Korea Clinical Features Most frequent general symtoms and signs were dizziness (18. 3%) and nausea, vomiting (8. 5%), and visual disturbance (8. 5%). Most frequent local symptoms and signs were swelling (98. 6%) and pain (83. 1%) No death of 71 cases (Cho NS, Park J. A clinical analysis of snake bite injury. J Korean Soc Emerg Med 1996; 7: 405 -14. ) www. themegallery. com
Snake Bite in South Korea Clinical Features Most frequent general symtoms and signs were dizziness (30%) and nausea, vomiting (20%), visual disturbance (20%), and fever (17%). Most frequent local symptoms and signs were swelling 50 (100%) and pain (100%) 45 40 35 No death of 100 cases 30 (Jang IS, Lee JA, Kim SY, et al. Clinical features in snake bite. J Korean Soc Emerg Med 1996; 7: 580 -9. ) www. themegallery. com 25 20 15 10 5 0 0 1 2 Grade of envenomation 3
Grading of envenomation Gr O : no envenomation a. minimal pain b. less than 2. 5 cm of surrounding edema or erythema c. no systemic manifestation during first 12 hrs d. no lab change Gr I : minimal envenomation a. fang wound is usually present b. moderate pain or throbbing localized at fang wound c. 12. 5 cm of edema and erythema d. no systemic manifestations during first 12 hrs e. no lab change
Grading of envenomation Gr II : moderate envenomation a. more severe and widely distributed pain b. edema spreading toward the trunk, and petechia & echymosis limited area of edema >12. 5 cm c. nausea/vomiting, mild fever Gr III : severe envenomation a. 12시간내에 edema spreads up the extrimity and may involve part of trunk b. generalized petechia and echymosis c. tachycardia, shock like state, subnormal temperature Gr IV : very severe envenomation a. large rattlesnake bite때 흔히 보임 b. sudden pain c. rapidly progressive swelling : 수시간 내에 trunk를 involve하며 necrosis 유발 d. 15분 정도내에 weakness, N/V, numbness/tingling of lips or face, vertigo, painful muscular cramps, shock, convulsion, coma, death
prehospital care of snakebite Rejected or Controversial First Aid Meathods l l Suction and Incision Electric shock treatment of the bite site Ice-water immersion Tourniquets www. themegallery. com
prehospital care of snakebite 1. calming the victim 2. immobilizing the bitten area at or below the level of heart 3. not giving anything by mouth(특히 alcohol) 4. lympahatic constricting band : a. thick pad & tight bandage over the bite wound b. no incision & ice 5. careful observation of ABC and establishment of IV line
ED care of snakebite 1. large-bore IV line : Ringer' lactate or normal saline 2. lab : CBC, U/A, EKG, platelet count, PTT, fibrinogen, FDP, electrolytes, BUN, creatinine, blood typing and CM 3. close monitoring of V/S 4. serial measurement of circumference and check distal pulse for fasciotomy 5. tetanus prophylaxis and antibiotics 6. use of antivenin : 증명된 유일한 치료 7. FFP, platelet
Antivenom Freeze-Dried Agkistrodon Halys Antivenom n Grade Vial 0 0 1 0 2 1 3 2 4 3 Jun DH, Lee DP, Choi WI. Initial assessment of the snakebites with local effects. J Korean Soc Emerg Med 2004; 15: 523 -30. www. themegallery. com
Compartment syndrome l Fasciotomy - compartment pressure > 30 mm Hg - distal pallor, paresthesia, or pulselessness
열응급 (Heat emergency) 차례 l l l 서론 열조절 기전 열경련(Heat Cramp) 열실신(heat syncope) 열피로 또는 일사병(Heat Exhaustion) 열사병(Heat Stroke)
Normal Thermoregulation
Heat Index chart
Types of Heat Emergency 1. 열경련(Heat Cramp) 2. 열피로 또는 일사병(Heat Exhaustion) 3. 열사병(Heat Stroke) 4. 열실신(heat syncope)
열피로(heat exhaustion)
Pathophysiology of heat stroke Exertion or heat exposure Heat stress Thermoregulatory response Cutaneous vasodilataion Heat shock protein production Spianchinc vasoconstriction Sweating Intestinal ischemia Dehydration Cytotoxic and inflammatory response ↑Vascular permeability ↑Intestinal wall permeability Renal failure Endotoxemia Heat stroke and circulatory shock Coaculation cascade
열사병(heat stroke) 뇌영상 - An 18 months old child - Axial CT scan on the 4 day after heat stroke. th MRI Brain on Day 45. Axial FLAIR image MRI Brain on Day 45. T 2 weighted image
Characteristics of heat stroke patients Characteristic Classic Exertional Total P-value Age(Mean±Sd, years) 68. 1± 16. 2 42. 0± 14. 8 0. 001 12: 8 20: 0 7: 0 0: 7 61. 3± 19. 4 19: 8 20: 7 05 10 11 7 0 0 7 2 0. 001 0. 026 0. 283 0. 026 0. 385 5 5 4 2 2 2 1 0 3 0 0 0 0 1 2 12 10 5 17 13 15 5 5 4 2 2 2 1 1 5 Sex (Male : Female) Cause (Classic : Exertional) Place Out-of-door Bathroom Home Transfer from other hospital Arrival interval < 2 hours Underlying disease Hypertension Stroke Diabetes Mellitus Cardiac disease Renal disease Lung disease Schizophrenia Mental retardation Death 0. 068 0. 283 0. 545 1 1 0. 259 0. 580
clinical characteristics between survival group and non-survival group in heat stroke at admission Survival (n=22) Non-survival (n=5) Total (n=27) P value N Mean±Sd SBP① (mm. Hg) 22 124. 3± 35. 2 5 95. 2± 32. 2 27 118. 9± 35. 9 0. 111 DBP② (mm. Hg) 22 065. 5± 13. 4 5 45. 8± 17. 7 27 61. 8± 15. 9 0. 053 MAP③ (mm. Hg) 22 85. 1± 18. 3 5 62. 3± 20. 5 27 80. 8± 20. 4 0. 034 Heart rate (/min) 22 121. 3± 24. 3 5 119. 4± 18. 8 27 120. 9± 23. 0 1. 000 Respiratory rate (/min) 22 23. 9± 6. 4 5 31. 0± 8. 2 27 25. 2± 7. 2 0. 048 Body temperature (℃) 22 39. 8± 2. 3 5 38. 8± 2. 2 27 39. 6± 2. 2 0. 274 CVP④ (cm. H 2 O) 16 11. 0± 5. 4 4 5. 1± 2. 7 20 9. 8± 5. 4 0. 033 22 9. 6± 4. 7 5 5. 4± 2. 4 27 08. 8± 4. 6 0. 089 Vital sign GCS score 8 9 5 14 0. 041 Seizure 4 1 5 1. 000 Intubation 11 4 15 0. 342 Cooling within 2 hours 19 0. 001 ①SBP ③MAP = systolic blood pressure, ②DBP = diastolic blood pressure, = mean arterial pressure, ④CVP = central venous pressure
risk variables between non-survival and survival groups Non-survival N Mean std N Age (years) 5 21. 2 1. 1 17 20. 5 0. 8 0. 139 Body mass index (kg/m 2) 3 25. 1 2. 4 16 23. 3 2. 8 0. 287 Acclimatization period (days) Military rank New recruit Above private* Type of exercise March Others† 5 2 3 3 2 175 17 11 6 79 Temperature (℃) 5 32. 3 1. 2 17 30. 1 3. 2 0. 135 Humidity (%) 5 77. 6 9. 4 17 72. 0 7. 4 0. 327 Wind speed (m/sec) 5 1. 5 0. 8 17 1. 6 0. 5 0. 783 Cloudy (%) 5 33. 6 25. 5 17 56. 7 29. 3 0. 100 5 3 2 4 1 369 Variables Survival Mean std p-value Individual factors 150 123 0. 196 0. 609 1. 000 Atmospheric conditions Pre-hospital managements Transfer time (minutes) Fluid infusion yes no Cooling yes no 214 12 13 4 10 7 256 159 0. 429 0. 585 0. 613
initial status between non-survival and survival groups Variables Vital sign Systolic blood pressure (mm. Hg) Body temperature (℃) Pulse rate (beats/minute) Initial laboratory findings White blood cell (× 1 03/μL ) Hemoglobin (g/d. L) Platelet (× 1 03/μL ) Sodium (mmol/L) Potassium (mmol/L) Blood urea nitrogen (mg/d. L) Creatinine (mg/d. L) Arterial p. H HCO 3 -(mmol/L) AST (IU/L) ALT (IU/L) Amylase (U/L) Seizure attack and Intubation Seizure attack yes no Intubation yes no Non-survival N Mean Survival std N Mean std p-value 5 5 5 77. 4 40. 4 128. 4 20. 6 0. 9 11. 0 16 16 16 119. 8 40. 0 125. 3 24. 8 1. 3 21. 3 0. 004 0. 615 0. 815 5 5 5 17. 68 12. 0 55. 6 149. 8 5. 8 43. 4 7. 188 12. 9 624. 8 730. 8 1836. 6 8. 35 3. 5 27. 3 7. 1 2. 1 19. 3 4. 69 0. 123 1. 8 519. 8 350. 1 1457. 8 15 15 13 13 14 14 13 17. 27 12. 8 126. 9 145. 6 4. 3 29. 2 2. 19 7. 360 17. 8 306. 9 196. 3 393. 3 8. 32 1. 6 77. 5 8. 6 0. 6 18. 5 1. 15 0. 050 3. 9 275. 5 203. 8 384. 3 1. 000 0. 599 0. 021 0. 358 0. 073 0. 074 0. 002 0. 020 0. 229 0. 004 2 3 4 1 8 9 5 12 1. 000 0. 116
열사병 – 감별 진단 l l l l l CNS hemorrhage Toxin/drug Seizure Malingnant hyperthermia Neuroleptic malignant syndrome Serotonine syndrome Thyroid storm High fever/sepsis Encephalitis/meningitis
열사병 - 급속냉각법 l Coolig blanket l l l 다른 냉각법과 같이 사용 IV cooling device Cardiopulmonary bypass
열사병 – 합병증 치료 l Benzodiazepine l l Sedation Seizure control Shivering control Chlorpromazine l l Vigorous Shivering control 주의 : anticholinergic property
Thank you!
- Slides: 64