Transcript Medicine For Mariners “101” - Old Point Comfort Yacht Club

Medicine For Mariners
“101”
Robin B. Garelick, MD, FACEP
SV Quantum Leap
Objectives

Learn and Have Fun
 Common Medical Conditions
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Seasickness
Hypothermia
Hyperthermia
Sunburn
Trauma
Marine Evenomation
Wound Care
Customizing a Medical Kit
 Basic First Aid Tips
 Future Topics and Workshops ?
Mal de Mer
“Seasickness”
AKA: Motion Sickness
Seasickness
 Throughout
the world, it is the most
frequent medical problem responsible for
maritime search and rescue.
 Primarily during stormy weather.
 Can cause a lack of will to persevere in
stormy weather and rough seas.
 “Wet, seasick and scared - they want to go
home”.
Seasickness can cause…
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Mental Deterioration
Physical Deterioration
Progressive Dehydration
Loss of Manual Dexterity
Ataxia (walk like you’re drunk!)
Impaired Judgment
After several hours of illness - loss of will to
survive
Fatalities due to poor seamanship &
complications during emergency evacuation
What does
seasickness look like ?
Basic Underlying Mechanism
of Seasickness
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Your body, inner ear and eyes all send different
signals to the brain.
 A disturbance occurs in the inner ear.
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Fluid within the vestibular system shifts in relationship
to position.
Position sensors in our muscles and joints send
signals to the brain based upon our movements.
 Our eyes may have a fixed position when below
deck or trying to read.
 Neural mismatch occurs while we are in motion.
The inner ear & it’s 3 canals
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Semicircular Canals
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Purpose of canals is so
we stay balanced and live
in 3D world
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3 Planes of Space
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Up-Down
Left-Right
Front-Back
The anatomy of motion
sensors…
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Canals are lined with
haircells.
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The fluid in the canals is
called endolymph.
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The haircells are our
motion sensors and when
the endolymph moves - a
message is sent to our
brain.
The neural mismatch
 Dopamine
(neurotransmitter) is released
and triggers a chemoreceptor zone in the
brain which activates our “vomit” center.
 Initial response to the neural mismatch
occurs at the brainstem level.
 So how do we prevent this or blunt the
response????
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AKA: How to get your sea legs.
Getting your sea legs…
 Occurs
over 24 to 72 hours.
 For many - the brain learns to compensate
over time and you accommodate.
 Medication prevents symptoms but may
not completely reverse once they occur.
 After a prolonged period of time at sea the
reverse occurs as you get used to being
on land.
Signs and Symptoms
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Sleepiness and excess yawning
Nausea (stay positive and tell yourself you won’t
vomit)
Extreme Nausea and Vomiting
Dizziness
Headache
Pallor
Cold Sweats
Depression
Lack of interest
Seasickness Triggers
 Going
below deck for extended periods of
time while underway.
 Looking through binoculars for extended
periods of time (stabilizing binoculars).
 Reading a book, focusing on compass,
detailed work or staring at one point.
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Keep peripheral vision on the horizon and not
staring at an object your brain will interpret as
stable because your semicircular canals are
screaming motion.
Preventative Measures
 Avoid
alcohol.
 Get plenty of rest before departing.
 Drink plenty of water and stay hydrated.
 Avoid heavy foods and fatty meals while
underway.
 Consider seasickness aids.
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Ginger
Homeopathics
Accupressure/Seasickness Bands
Medications for Seasickness
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Antihistamines:
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Anticholinergics:
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Meclizine (Bonine, Non -drowsy Dramamine)
Cyclizine (Marazine)
Diphenhydramine (Benedryl)
Cinnarizine (Stugeron)
Scopolamine (Transderm-Scop)
Antiemetics
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Promethazine (Phenergan tablet or suppository)
Prochlorperazine (Compazine)
Metoclopramide (Reglan)
Odansetron (Zofran)
Side Effects of Medications
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Antihistamines & Anticholinergics:
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Serotonin Receptor Antagonists:
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Sedation/Drowsiness
Dry Mouth
Blurred Vision
Headache
Fatigue/Malaise
Antiemetics (except Odansetron/Zofran):
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Akasthesis/Dystonia
Sedation
Hypothermia
AKA: I’m Cold
 Primary
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& Secondary Hypothermia
Primary: Cold Exposure
Secondary: Medical Conditions or
Medications that prevent response to cold or
predispose to heat loss.
 Immersion
(Man overboard!!!!)
 Acute versus Chronic
Hypothermia Defined
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Mild Hypothermia: core temperature below 95o
to 89.6o.
Moderate Hypothermia: core temperature below
89.6o to 82.4o.
Severe Hypothermia: core temperature less than
82.4o.
We set 86o as the CRITICAL Temperature.
Mild and early moderate hypothermia are
treatable without emergency medical
intervention & rescue.
Acute vs.Chronic
Hypothermia
 Thermal
Conductivity of water: 25 times
greater than air.
 Acute Hypothermia develops in minutes to
hours after sudden immersion in cold
water.
 Chronic Hypothermia develops over hours
to days when inadequate protection from
cold wind and wet spray.
Predictable Rate of Cooling
 Based
on water temperature
 Body shape (short round bodies cool
slower than tall thin bodies).
 Insulating fat layers (finally an advantage
to having more sub-q fat).
 If immersed - activity during immersion
(less is better).
 Amount of body immersed.
 Protective clothing being worn.
How do we preserve heat ?
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Divert warm blood from the surface to our core.
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skin and muscles to the brain, heart, lungs, kidney
and liver.
The decrease in surface blood flow improves
insulation
 Shivering occurs to produce heat by increasing
metabolic activity. Max shivering at 89.6o to
91.6o.
 Hypothermia develops when heat loss exceeds
heat conservation.
 Muscle rigidity occurs at 86o.Voluntary shivering
stops with we are unable to rewarm ourself.
Signs and Symptoms
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Clumsiness in activity.
Difficulty walking (especially with heavy gear or
clothing).
Subtle changes in mental status which impair
judgment (confusion and disorientation).
Decreased responsiveness to verbal and painful
stimuli.
Coma and unconscious state in severe
hypothermia.
Treatment of Hypothermia
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Initial treatment in mild hypothermia:
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Take shelter from wind and water.
Replace wet clothing with multiple layers of dry
insulated garments that make the skin feel dry.
If no dry clothing then add an extra layer of foul
weather gear.
Wrap in blankets, sleeping bag, sail or sailbags.
Feed simple carbs and light sweet beverages (warm
preferred)
Allow shivering to continue for self rewarming.
In moderate to severe hypothermia - evacuation
is required for emergency medical intervention.
Treatment of Hypothermia
 In
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moderate to severe hypothermia:
Heart can be stunned into ventricular
fibrillation - therefore handle the victim gently.
Lay victim flat.
External hot packs to the armpits, groin, chest
wall and neck to stabilize body temperature.
Cuddle to help stabilize their body
temperature.
Cough and gag reflexes are diminished - do
not try to give hot liquids or food.
 Remember
to keep them bundled and
protected from cold.
 Helicopter rescue may incur winds of 100
mph from prop downwash and increase
wind-chill for the hypothermic victim.
Survival Gear
Hyperthermia
AKA: I’m hot
 Definition:
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A medical condition arising when the body’s
capacity to lose heat does not match the total
body heat load.
Occurs when a normal physiologic response
becomes pathophysiologic (body temperature
> than the brain set point).
Types of Heat Illness
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Heat Rash: rash caused by plugged sweat
glands and we get a secondary inflammatory
reaction.
Heat Edema: self limited swelling of the hands
and feet seen early in heat exposure.
Heat Cramps: muscle cramps associated with
exercise and secondary to loss of sodium.
Heat Syncope: fainting from dilatation of the
surface blood vessels from high temperature.
Heat Exhaustion: Loss of circulating volume in
the face of heat stress.
Types of Heat Illness
 Heat
Stroke: complex clinical condition
characterized by:
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Core temperature of 104o to 106o.
Neurologic Changes (aka: change in mental
status)
Multiorgan dysfunction can occur - breakdown
in ability of kidneys and heart to function
within normal limits.
How do we lose heat ?
 Radiation:
65% of heat loss
 Conduction: < 2% of heat loss (increases
when immersed in water)
 Convection: 10% of heat loss
 Respiration/Breathing: 5% of heat loss
 Evaporation: 35% at rest and up to 75% of
heat loss with activity.
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Most effective means of heat loss BUT at 95%
humidity, evaporation no longer occurs.
Factors that Predispose us to
Hyperthermia
 Prolonged
exertion
 Poor muscle conditioning
 Inability to acclimate to the temperature
 Sleep deprivation
 Disease states
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Cardiac, dehydration, endocrine disorders,
skin disorders, infections, seizures, etc.
Factors that Predispose to
Hyperthermia
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Rapid change in humidity or temperature
 Heavy and/or constrictive clothing
 Extremes of age - the very young and the very
old…
 Medications & Drugs
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Anticholinergics: TCA’s and Phenothiazines
Amphetamines & Cocaine
Diuretics (water pills)
Alcohol
Beta Blockers (drugs that end in -ol)
Alpha agonists
Signs and Symptoms of Heat
Exhaustion
 Malaise
 Weakness
(low blood pressure)
 Headache
 Decreased Appetite
 Nausea/Vomiting
 Increased
heart rate
 Profuse sweating
Heat Stroke
 True
Medical Emergency that requires
rapid cooling measures:
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While awaiting assistance - remove excess
clothing.
Try cooling methods such as body misting,
fan, cool wet sheets r ice packs to the groin,
axilla, neck and chest area.
Rapid cooling improves survival.
Treatment of Hyperthermia
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Hydration, hydration, hydration!!!
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“If you can read the newspaper through your urine you’re well hydrated.”
Electrolyte drinks like Gatorade or Powerade
(avoid salt tablets).
Avoiding excess heat with medication/medical
conditions that predispose to heat illness.
Decrease alcohol consumption.
Minimize sun exposure.
Avoid sleep deprivation.
Decrease outdoor activity/exercise routines and
shift to an indoor environment.
Treatment of Hyperthermia
 Avoid
sleep deprivation.
 Decrease outdoor activity/exercise routine
and shift to indoor environment.
 Cold showers/transom shower/anchor
washdown.
 If going to a hot climate - acclimate slowly
over a period of 1 to 2 weeks.
Sunburn and Solar Injury
 Sunburn
is classified as a thermal injury.
 Red,
hot painful 1st degree burns show up
2 to 6 hours after exposure.
 2nd
degree burns occur when there is
swelling, blisters and subsequent peeling.
Sunburn Prevention
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Schedule water activities (when possible) in
early morning or late afternoon hours.
 Chemical sunscreens (PABA) absorb UV rays
and require application at least 30 to 60 minutes
prior to sun exposure so they can penetrate the
deep layers of the skin.
 Physical sunscreen (zinc oxide) act as physical
shields and reflect or scatter light. They are
effective immediately.
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Use on high exposure areas: lips. ears, facial areas.
Sunburn Prevention
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Reapply liberally every 2 to 3 hours and more
frequently if in and out of the water or excess
perspiration.
 Waterproof formulations last 2X longer than
water resistant formulations.
 Consider UV block clothing and hats that cover
sensitive areas (face/ears/neck/scalp)
Sun Related Eye Injuries
 Excess
UV Radiation can lead to cataracts
and damage to the retina.
 Photokeratitis is a “sunburn” type injury to
the cornea:
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Intense eye pain
Increased tearing & redness
Spasm of the eye itself as well as the lid
Sun Related Eye Injuries
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Pain & temporary loss of vision starts in 4 to 12
hours.
 Treatment is with antibiotic ointment or solution.
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Bacitracin Ophthalmic Ointment
Polytrim Eye Drops
Cipro Eye Drops (Contact lens wearer)
Avoid bright light after a photosensitivity injury
(24 hours).
 Pain medication
 Sunglasses that block UVA & UVB with a wide
brimmed hat.
Photosensitivity Reactions
 Exagerrated
sunburn or rashes triggered
by sun exposure after taking a particular
medication or applying a chemicla or plant
extract to the skin.
 Burn appears immediately and lasts up to
2 to 4 days.
 May get hives or poison ivy type rash.
Treatment of Photosensitivity
Reactions
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Mild: treat like you would a sunburn.
 Moderate to Severe:
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May require prednisone (steroids).
Pain medication
Remove offending agent (if not a required medication)
Stay out of the sun
Use sunblock frequently and generously.
Read the label on all medications and check
manufacturer websites.
Sun Poisoning
 Severe
reaction after intense sun
exposure.
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Fever & Chills
Headache
Nausea & Vomiting
Dehydration and may experience altered
mental status if the blood pressure falls
Treatment is the same as heat exhaustion
with the addition of prednisone for the most
severe reactions.
Drugs that Cause
Photosensitivity Reactions
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Antibiotics:
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Cyclines
Flouroquinolones
(Cipro, Levaquin,
Avelox)
Bactrim/Sulfonamides
Nalidixic Acid
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Antihistamines
 Antiparasitics
 Antihypertensives
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Captopril
Diltiazem
Nifedipine
Drugs that Cause
Photosensitivity Reactions
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Anti-Inflammatory
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Motrin/Ibuprophen
Indocin
Naprosyn
Piroxicanm (Feldene)
Miscellaneous
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Diuretics
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Diamox
HCTZ
Lasix/Furosemide
Trimaterene (Maxzide)
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Benzocine
Benzoyl Peroxide
OCP
Topical Cortisone
Amiodarone
Xanax
Retin-A/Accutane
Hypoglycemics
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Glipizide
Glyburide
Tolbutamide (Orinase)
Sunscreens that Cause
Photosensitivity
 Preps
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containing the following:
Aminobenzoic Acid
Avobenzone
Benzophenones
Cinnamates
Homosalate
Methyl Anthranilate
PABA Esters
Treatment of Sunburn
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Cool wet compresses for 15 to 20 minutes every
hour.
Frequent cool showers or duse with cold sea
water.
Pain medication (Ibuprophen, narcotic
analgesics).
Topical aloe vera gel for comfort and healing.
Antibacterial Ointment
Lidocaine jelly or anesthetic sunburn spray.
Leave blisters intact as your own body fluid &
skin are a natural barrier and promote healing.
Perfumes, Lotions and Cosmetics
that Cause Photosensitivity
 Bergamot
Oil
 Oil of Citron, Lavendar, Cedar, Lime,
Sandalwood, Citrus Rind Oils and 6methylcoumarin
 Hexachlorophene (Phisohex, etc.)
Trauma 101
 Sprains,
strains, fractures, contusions,
dislocations…..
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All bets are off out to sea!
 Chest
and head trauma are the most
common injuries for recreational boaters.
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Head Injuries include both blunt and
penetrating trauma.
Chest injuries include both blunt and
penetrating trauma
Head Injuries
 Falls,
hit in the head with flying objects
and naturally the “boom” .
 Cuts to the face and scalp.
 Blunt trauma to facial bones.
 Nose bleeds secondary to facial trauma.
What to look for with a head
injury
 Was
there a loss of consciousness
(+LOC)?
 Is amnesia present?
 Do they have normal speech, mentation
and are they moving all extrmities?
 Is there a complaint of numbness or
tingling in an arm or leg?
 Is there nausea/vomiting?
 Is there a complaint of blurry vision?
Ouch!!!!!
Treatment of Head Injuries
 If
there is neurological abnormality immediate evacuation with emergency
medical attention.
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Prolonged loss of consciousness
Numb/Tingle in extremities or an inabilty to
use an extremity without signs of a broken
bone
Remember to try and immobilize the neck
Treatment of Head Injuries
 If
there is a brief LOC then it may be safe
to remain onboard and observe carefully
for the next 24 hours.
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Signs of a more severe injury include:
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Nausea/Vomiting
Vision Changes
Dizziness
Change in speech
Change in mentation
Chest Injuries
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are from blunt force:
Can cause rib fractures.
If ribs are fractured then make sure the
injured person can breath comfortably as they
are at risk of puncturing their lung from a
broken rib.
What does the rib cage look
like ?
Examination of the Chest Wall
 Expose
the area to look for any open
wounds.
 Feel along the chest wall front and back to
see if there are “rice crispies”.
 Feel the breast bone for tenderness.
 Look for any deformity of the collar bones.
 Watch the breathing pattern - is it regular
or short and gasping?
Treatment of Chest Injuries
 Pain
medication.
 Ice bruised areas found when you
examine the chest.
 Duck tape???
 Monitor for any changes in breathing and
pain increase with inspiration (taking a
breath).
Sprains, Strains, Fractures &
Dislocations
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RICE: rest, ice, compression and elevation.
Pain Medication
If a bone appears deformed - splint in
anatomically and place in a position of comfort.
If severe deformity then medical attention is
required.
Blood loss can happen with long bone fractures.
Nerve injuries can occur with dislocations and
fractures - if not treated in a timely manner.
Not sure then summon help.
Sam Splint - My Personal
Favorite
Sam Body
Sam User Guide
Other SAM Products
Marine Evenomation
The Jellyfish Sting
 Reactions
vary b the type of jelly fish,
venom potency and the amount injected.
 Symptoms vary from burning to itching to
excruciating pain.
 Anaphylaxis with difficulty breathing, drop
in blood pressure and shock.
Treatment of Jellyfish Sting
 Apply
vinegar (Acetic Acid 5%)
immediately to inactivate the venom.
 If vinegar is not available use sea water.
 NEVER rinse with fresh water or apply ice
directly to the skin as it will activate
stinging cells and increase pain/reaction.
 If eyes are involved irrigate immediately
with saline or sea water.
Treatment of Jellyfish Sting
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Rubbing alcohol and vinegar can help with pain
over the first hour.
Baking soda paste provides relief.
1/4 strength household ammonia may help.
Limited usefulness of meat tenderizer.
Remove embedded particles or tentacles with a
tweezer. Wear protective gloves. You can also
apply shave cream and shave the skin gently.
Hydrocortisone Cream
Prednisone and Benedryl
If stung on the mouth - watch for swelling.
Wound Care
 All
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bleeding stops with pressure.
Apply direct pressure over the wound for 15
minutes and elevate the affected body part.
Neck wounds - pinch the area instead of
pressure.
Wound Care
 Clean
wounds with saline or fresh water
kept onboard specifically for wound care
(boiled and stored).
 Alcohol and Hydrogen Peroxide applied
full strength can be toxic to tissues.
 “If you can’t put it in your eye then don’t
put it in your wounds”.
 Other wound care information
Methods of Wound Closure
 Bandaid
 Butterfly
Bandaid
 Steristrips
 Occlusive Dressing
 Skin Glue
 Staples (surgical staples)
 Sutures
Checking the Wound
 Monitor
carefully for signs of infection and
age appropriate healing.
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Pus draining from wound
Pain, redness and swelling
Fever and Chills
Swollen tender lymph nodes
Red streaking in the affected area
Choosing Your Medical Kit
 Based
on how far you will travel and your
health history.
 Easy to stow and easily accessible to all
onboard.
 Basic supplies versus advanced medical
kit
Adventure Kits
Adventure Kits
Other First Aid Kits
Godspeed