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  1. Early recognition and implementation of appropriate therapy is essential in the care of the patient who has suffered environmental injury.

  2. The 2 main forms of heat stroke are exertional and nonexertional. Rapid initiation of cooling is essential to management.

  3. The mildly hypothermic patient should be rewarmed at a rate of 0.5 to 2°C/h. Indications for a more rapid rate include cardiovascular instability and temperature below 32°C.

  4. In the pre-hospital management of frostbite, protect the affected area from thawing; if thawing is inevitable, then prevent refreezing. In the hospital, immerse the affected body part in circulating water 37°C to 39°C.

  5. Seek expert toxicology advice if considering administration of antivenom in the management of injury incurred by Crotalidae (pit vipers), black widow spiders, or scorpions.

  6. A thorough physical examination will dictate the management of lightning injury, with specific attention paid to the integument, tympanic membrane, and eye.

  7. The physical examination can be misleading following electrical injury. Deep tissue injury may result in compartment syndrome and rhabdomyolysis.

  8. The acute radiation syndrome afflicts 3 systems: hematopoietic, gastrointestinal, and integument.


Man's interactions with the environment may result in an untoward affliction of injury for both. From the patient's standpoint, the common theme in prevention of environmental injury is preparedness and sound awareness of environmental factors. From the practitioner's standpoint, a sound grasp of the diagnosis and management of these relatively rare presentations may aid the patient in these sometimes-critical settings. This chapter will focus on heat stroke, accidental hypothermia, drowning, envenomation, electrical injury and injury due to ionizing radiation. Emphasis will be on basic understanding of the epidemiology, pathophysiology and management of the individual disorders, with some added focus on problems the practitioner might encounter in the critical care setting. For detailed discussions of the individual disorders the reader is advised to consult the references.

One common theme among all disorders included in this chapter is the need for their early recognition and speedy initiation of appropriate therapy in the prehospital environment and emergency department, with critical care continuing such care and management of any associated organ failures in the in-hospital setting. Any deviation from such timely response is likely to result in significant additional injury and increased risk of poor outcome.


Essentials of diagnosis are as follows:

  • Temperature > 40°C (104°F)1,2,3,4,5

  • Central nervous dysfunction

General Considerations

The body's basal rate of metabolism is responsible for heat generation. Almost all energy released in the body will end in heat production. The body's core temperature is maintained in the vicinity of 36°C to 37.5°C to ensure optimal functioning of the enzymatic and molecular machinery. The principal responses to an elevated core temperature are vasodilatation and sweating. Vasodilatation intensifies the rate of heat transfer ...

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