Environmental Emergencies

Review Test

1. Parents bring in a two-year-old girl after they found her chewing on an
electrical cord. Burns to the corners of her mouth are visible, but the rest of the
physical examination and work-up is otherwise negative. The parents should
be warned about which of the following potential complications in this child?

(A) Renal Failure
(B) Cardiopulmonary arrest
(C) Infection
(D) Bleeding
(E) Neurological deficits

2. A 26-year-old man is brought to the emergency department (ED) after
collapsing within minutes of completing an underwater dive and returning to
the surface at a nearby resort. Which of the following is his most likely

(A) Decompression sickness
(B) Acute gas embolism
(C) Reverse squeeze
(D) Squeeze
(E) Pulmonary overpressurization syndrome

3. A 5-year-old girl presents with a burn to her arm. The area is painful, red, and
dry, but has no blisters. The remainder of the physical examination is normal.
Which type of burn does this child most likely have?

(A) First-degree burn
(B) Second-degree burn
(C) Third-degree burn
(D) Eschar
(E) It is not possible to tell from the description given.

4. Which of the following features is associated with poisonous snakes?

(A) Round pupil
(B) Presence of fangs
(C) Absence of a pit between eye and nostril
(D) Round head
(E) All of the above


5. Which of the following bites may be sutured at presentation (primary

(A) J ellyfish bite (sting) to the foot
(B) Dog bite to the face
(C) Ferret bite to the head
(D) Human bite to the hand
(E) Sea nettle bite (sting) to the ankle

Directions: The response options for Items 6-9 are the same. You will be required
to select one answer for each item in the set.

Questions 6-9

For each environmental injury, select the characteristic ECG finding.

(A) J (Osborne) wave
(B) Premature ventricular contractions
(C) Asystole
(D) Digitalis effect

6. Lightning injury

7. Hypothermia

8. Black widow spider bite

9. Electrical burn

Directions: The response options for Items 10-13 are the same. You will be
required to select one answer for each item in the set.

Questions 10-13

Match each type of bite to the bacteria that is most likely to cause infection in that

(A) Pasturella multocida
(B) Capnocytophaga canimorsus
(C) Eikenella corrodens
(D) Streptobacillus moniliformis

10. Dog
11. Cat
12. Rodent
13. Human

Answers and Explanations

1-D. Oral electrical burns have a tendency to present with delayed (1-2 weeks
later) bleeding from the labial artery. Parents should be warned about this
complication at the time of discharge. Usually the bleeding can be controlled with
pressure, and further treatment is not necessary. Electrical injuries can present
with renal failure and cardiopulmonary arrest, but these are early rather than late
complications. Neurological deficits are also possible, but they are unlikely in this
child, who had local injury. Infection is not a usual sequela of electrical burns;
rather, it is seen with thermal burns.

2-B. The classic presentation of an acute gas embolism (AGE) is syncope within
10 minutes of ascending from a dive. AGE is caused by gas bubbles entering the
systemic circulation from ruptured pulmonary veins. Decompression sickness
follows later. Reverse squeeze and pulmonary overpressurization syndrome also
occur during ascent, but are not characterized by syncope. Squeeze occurs during
descent, not ascent.

3-A. This child’s burn fits the description of a typical first-degree burn. Second-
degree burns usually present with blisters. Complete third-degree burns usually
are painless. Eschars are associated with third-degree burns.

4-B. The presence of fangs is associated with poisonous snakes. All the other
features listed – round pupil, absence of a pit between eye and nostril, and a round
head- are associated with non-poisonous snakes.

5-B. Dog bites to the face have a low risk of infection (between 1% and 5%) and
therefore can be closed primarily. Dog bites to the hand or those involving crush
injury are not closed primarily. Ferret bites are puncture wounds, and these are not
closed. Human bites to the fist are described as closed fist injury. They are not
close primarily either, because of the potential complications of tenosynovitis,
septic arthritis, and osteomyelitis. Similarly, marine venomous animal bites are
not sutured because of high risk of infection.

6-C, 7-A, 8-D, 9-B. Certain environmental problems have characteristic, although
not pathognomonic, ECG findings that may be useful in leading to the correct
diagnosis, especially when no history is available.

10-B, 11-A, 12-D, 13-C. Although various bacteria can be found in many
different bites (e.g., P.multocida in cat, dog, and primate bites), certain bacteria
are more typically seen with certain types of bites. It is useful to know which
bacteria are commonly seen with specific types of bites when choosing antibiotics.


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