Environmental exposures

Environmental Exposures

I. Problem/Condition.

Exposure to environmental forces that dramatically alter normal human physiology and can result in significant morbidity and mortality. Diagnoses include the following:

1. Hypothermia

2. Hyperthermia

3. Near-Drowning

4. Burns/Radiation Exposure

5. Electrical Injury

6. Stinging insect hypersensitivity

7. Carbon Monoxide

8. Smoke Inhalation

9. Drug overdose and poisoning

II. Diagnostic Approach.

A. What is the differential diagnosis for this problem?

  • Hypothermia



    Hypothyroidism (myxedema coma)


    Hypothalamic Stroke

    Exposure Hypothermia

  • Hyperthermia – temperature greater than 104 °F

    CNS Damage/infection

    Neuroleptic Malignant Syndrome

    Serotonin Syndrome

    Anticholinergic toxicity

    Heat stroke

    Sympathomimetic toxicity

    Endocrine disturbance (Hyperthyroidism, pheochromocytoma)

  • Drowning

    Head trauma

    Congestive heart failure/pulmonary edema



    Pulmonary Embolus


    Myocardial infarction




  • Burns/Electrical Injury/Radiation exposure



    Necrotizing fasciitis

    Radiation exposure

    Severe abrasions

    Electrical Injury


  • Stinging Insect Hypersensitivity






    Stinging Insect Hypersensitivity

    Hereditary angioedema


  • Carbon Monoxide




    Vascular Shunt

    Viral Syndrome (e.g., influenza)


    Acute respiratory distress syndrome



  • Smoke Inhalation





    Acute respiratory distress syndrome


    Smoke inhalation

  • Drug Overdose/Poisoning

    Uppers (cocaine/crack, amphetamines, ecstasy, PCP, synthetic cannabinoids)

    Downers (alcohol, benzodiazepines, opiates, marijuana, hallucinogens)

    Toxins (acetaminophen, aspirin)

    Metals (Lead, Beryllium, Mercury, Arsenic)

    Organophosphates (OP)

B. Describe a diagnostic approach/method to the patient with this problem.

The key to any environmental exposure is a thorough and accurate history. If the patient cannot give the history, obtain a history from whomever brought the patient to the hospital. To determine the likelihood of any of these exposures, it is essential to consider the local weather, altitude, recreation, and industry. It is also important to consider risk factors for recreational drug use.

Historical information important in the diagnosis of this problem.

  • Hypothermia

    Where was the patient found?

    What is the current local weather? Is it winter or one of the coldest days of the year?

    Is the patient taking medications for diabetes or is he on insulin?

    Has the patient had a recent fever? Does the patient meet other systemic inflammatory response syndrome (SIRS) criteria?

    Is the patient malnourished?

    Does the patient have a history of endocrine disease or other signs of hypothyroidism or hypocortisolism?

    Is the patient greater than 65 years old?

  • Hyperthermia

    Is this patient taking antipsychotics or neuroleptics?

    Is this patient taking selective serotonin reuptake inhibitors (SSRIs) or monoamine oxidase inhibitors (MAOIs)?

    Has this patient taken cocaine, amphetamines, or another sympathomimetic?

    Is this patient taking anticholinergic medications?

    Does this patient have a history of endocrine disease? Does this patient have a history of hyperthyroidism or pheochromocytoma?

    Has this patient participated in strenuous exercise?

    Is it summer or one of the warmest days of the year?

    Is this patient greater than 65 years old?

    Does this patient have signs of meningitis or encephalitis?

  • Drowning

    Was this patient using drugs or alcohol while near water?

    Was this patient extremely fatigued or in poor physical health?

    Does this patient have a history of seizures, coronary artery disease, arrhythmias, or hypoglycemia?

    Does the patient have a history of depression or prior suicide attempts?

    Does this patient have a history of spinal cord or brain disease?

    Was this patient recently deep sea diving and at risk for decompression sickness?

    Is this patient an experienced swimmer?

    Did this patient sustain head trauma while near water?

  • Burns/Electrical Injury/Radiation exposure

    What does this patient do for a living?

    Was this patient recently involved in home or office repair?

    Does this patient work with open flames, extremely hot gas or liquids, electrical wires/outlets, or ionizing radiation?

    Has this patient been exposed to open flames, extremely hot gas or liquids, electrical wires/outlets, or ionizing radiation?

    Was the electrical exposure to low voltage (household; 110-220 V), intermediate (220-1000 V), or high (>1000 V)?

  • Stinging Insect Hypersensitivity

    Has this patient previously had a reaction to a sting from a bee, wasp, yellow jacket, or hornet?

    Has this patient recently been exposed to bees, wasps, yellow jackets, or hornets?

    Has this patient spent a significant amount of time outdoors recently?

    Does this patient have seasonal allergies or allergies to medications, lotions, perfumes, detergent, pets, pollen, or other substances?

  • Carbon Monoxide

    How is the living space of the patient ventilated and heated?

    Are there others living with the patient experiencing similar symptoms?

    Is it winter or weather cold enough to use heaters?

    How old is the patient’s heater?

    Does the patient use a generator for electricity?

    Is the patient regularly exposed to heavy exhaust fumes in a poorly ventilated space?

    Is the patient suicidal? Has he or she started a parked car in a closed garage?

  • Smoke Inhalation

    Has the patient been in proximity to any fires? If so, what kind of fire was it?

    Does the patient recall inhaling a significant amount of smoke?

    Does the patient have any facial burns?

    Does the patient have chest pain or shortness of breath?

    Does the patient have trouble clearing his or her oral secretions?

    Did the patient have loss of consciousness or change in mental status?

  • Drug Overdose/Poisoning

    Does this patient have a history of alcohol or recreational drug use?

    Does this patient have other high risk factors (e.g., promiscuous sex, psychiatric disease)?

    Is this patient suicidal or does he/she have a history of psychiatric illness?

    Does this patient work in an industry where he or she would be exposed to the following?

    Lead – Does he or she do electrical work? Does the patient do roofing, siding, or sheet metal work? Is the patient involved in shipbuilding, railroad industry, or automotive repair? Does the patient work with industrial solvents, paints, or sealants?

    Beryllium – Does the patient work in the atomic or defense industry? Does the patient work in space, aeronautics, computer, or electronics field?

    Mercury – Does the patient mine, transport, or produce mercury? Does the patient mine or refine silver or gold? Is the patient involved in the making of thermometers, gauges, or valves? Is the patient involved in the making of amalgams for dentists, preservatives, heat-transfer technology, pigments, catalysts, or lubrication oils?

    Arsenic – Is this patient involved in copper or lead smelting, wood treating, or pesticide application?

    Is the patient a farmer who has recently sprayed pesticides?

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.

  • Hypothermia

    Accurate measurement of core body temperature is necessary. This should be done using a rectal temperature probe or a Foley catheter with a temperature probe.

    Pupillary dilation may be seen with moderate hypothermia (temperature 82.4 °F to 89.6 °F).

    Bradycardia may be seen with moderate hypothermia (temperature 82.4 °F to 89.6 °F). Osborne waves can be seen on an EKG. Atrial fibrillation is the most common arrhythmia in hypothermia.

  • Hyperthermia

    Assessment for muscular rigidity is important for diagnosis of neuroleptic malignant syndrome.

    Spontaneous or inducible clonus is characteristic of serotonin syndrome.

    Tremor and hyperreflexia is characteristic of serotonin syndrome.

    Dry skin, flushing, and hypertension is characteristic of anticholinergic toxicity.

    Dry skin and hypotension is characteristic of heat stroke.

    Nuchal rigidity may be present in patients with meningoencephalitis.

    Agitation and delirium are characteristics of nearly all causes of hyperthermia.

  • Drowning

    Assess the consciousness level of the patient on the field.

    The drowning classification is widely used to treat on the field and as well as triage in the emergency room:

    Grade 6 – Cardiopulmonary Arrest

    Grade 5 – Respiratory arrest

    Grade 4 – Acute pulmonary edema with hypotension

    Grade 3 – Acute pulmonary edema without hypotension

    Grade 2 – Abnormal auscultation with rales in some pulmonary fields

    Grade 1 – Coughing with normal lung auscultation

    Rescue – No coughing or difficulty breathing, normal lung auscultation

    Rarely late onset pulmonary edema can occur 12 hours after the incident.

  • Burns

    A primary assessment includes a detailed dermatologic assessment. A determination of the percent of surface area involved is helpful in determining prognosis and treatment. As a general rule, when 20% or more of the skin is involved, the local tissue response becomes systemic and results in more severe pathophysiologic changes. In these patients, all organs should be assessed for interstitial edema due to capillary leak, especially the lungs.

    A secondary assessment includes a detailed medical history, mechanism of injury, and detailed systems based assessment from head to toe.

  • Electrical Injury

    A good contact to low and intermediate voltage can lead to a severe local wound but rarely to any systemic injury and needs a good dermatologic assessment.

    A good high voltage contact can cause compartment syndrome, myocardial injury, fracture of long bones and spine, rhabdomyolysis, and soft tissue burns.

    A careful cardiovascular assessment for asystole, ventricular fibrillation, heart blocks, and supraventricular tachycardias should be completed. Telemetry monitoring is recommended for 24 to 72 hours.

    Assessment for compartment syndrome in the extremities with serial examination is important.

    Dermatologic assessment for skin involvement should be thorough, keeping in mind that electrical burns may cause a significant degree of internal tissue damage and minimal external damage to the skin.

    Peripheral motor and sensory nerves should be assessed.

    The patient should be closely assessed for focal deficits and/or hidden spinal cord injury.

    Ophthalmologic and otoscopic evaluation is essential in cases of lightning injury.

  • Radiation Exposure

    Needs a careful examination of all mucosal surfaces and skin.

    A thorough CNS neurologic exam is necessary because the brain and spinal cord are sensitive to radiation.

    Pulmonary crackles may be suggestive of radiation pneumonitis.

  • Stinging Insect Hypersensitivity

    Assess for hypotension or shock from widespread vasodilation.

    Assess skin for flushing, which is consistent with anaphylaxis.

    Stridor is concerning for laryngeal angioedema.

    Wheezes are suggestive of bronchospasm.

    Urticaria and angioedema may present with and without anaphylaxis.

  • Carbon Monoxide Poisoning

    A full mental status exam and neurologic exam should be performed.

    Routine arterial blood gas testing gives falsely normal readings. A low pulse oximetry reading with normal partial pressure of oxygen is characteristic of carbon monoxide poisoning. Hence co-oximetry is required.

    Skin discoloration and cherry-red lips are a rare and late finding.

  • Smoke inhalation

    A complete pulmonary exam is essential to determine extent of injury.

    Bronchorrhea and bronchospasm are common after the acute injury.

    Sloughing of the bronchiolar mucosa may happen after 2-3 days resulting in worsening symptoms and hypoxemia.

    Bacterial pneumonia may present 5-7 days after exposure.

  • Drug Overdose/Poisoning

    Pupillary exam may aid in determination of the substance in an acute overdose.

    Skin exam for needle track marks or burns from smoking may aid in determination of the substance.

    A close examination of the fingernails may reveal findings suggestive of heavy metal environmental poisoning (transverse white lines, AKA Mee’s lines, are classically associated with arsenic poisoning, but may be seen in other heavy metal toxicities).

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

  • Hypothermia

    EKG should be ordered to assess for cold-induced arrhythmias.

    Urinary output should be closely monitored as oliguria may be seen at very low temperatures (<82.4 °F).

    A complete blood count (CBC), comprehensive metabolic panel (CMP), urinalysis, blood cultures, and chest x-ray should be ordered to assess for infection.

    A thyroid stimulating hormone (TSH) level and a serum cortisol level along with a cosyntropin stimulation test should be considered if there is no obvious explanation for hypothermia.

  • Hyperthermia (Temp > 104o F)

    Creatine kinase or aldolase should be ordered to assess for skeletal muscle injury.

    A lumbar puncture should be performed if there is not an obvious alternative explanation of the hyperthermia.

    A CBC, urinalysis, blood cultures, and chest x-ray should be considered to aid in elimination of fever as cause of elevated temperature.

  • Drowning

    An arterial blood gas (ABG) to assess hypoxia and a chest x-ray to assess for pulmonary edema should be performed immediately.

    EKG and cardiac enzymes to assess for myocardial infarction and/or arrhythmia.

    CBC, CMP, magnesium, phosphorus, coagulation studies (PT, aPTT), and lactate level should be performed.

    A CT scan should be done when head injury or cervical injury is suspected.

    Bedside glucose testing should be done quickly to assess for hypoglycemia.

    Toxicology screening should be done for alcohol and other drugs if suspected.

  • Burns/Electrical Injury/Radiation Exposure

    A serum CBC, CMP, magnesium, phosphorus, creatine kinase, lactate level, coagulation studies (PT, aPTT), cardiac enzymes, lactate level, and arterial blood gas should be performed.

    A urinalysis should be performed.

    A chest x-ray and EKG should also be performed to assess for pulmonary edema/pneumonitis and myocardial injury/arrhythmias.

    Blood cultures should be performed if pattern of skin breakdown suggests likelihood of infection.

  • Stinging Insect Hypersensitivity

    A serum IgE level may help confirm hypersensitivity.

  • Carbon Monoxide Poisoning

    Carboxyhemoglobin saturation level, although levels do not correlate with presentation or degree of injury.

    CBC, CMP, magnesium, phosphorus, creatine kinase, lactate levels, and arterial blood gas should be performed. Cardiac enzymes and EKG should be done when cardio toxicity is suspected.

    A pulse co-oximeter can distinguish oxyhemoglobin from carboxyhemoglobin and should be used to make the diagnosis.

  • Smoke Inhalation

    A chest x-ray is used to assess for pulmonary injury, but is usually believed to be an insensitive indicator of inhalational injury.

    Laryngoscopy should be done if there is evidence of upper airway compromise.

    An arterial blood gas and pulse co-oximetry should be performed. It is important to note that carbon monoxide may cause a normal partial pressure of oxygen and a low pulse oximetry reading. Cyanide level should be measured in the presence of unexplained metabolic acidosis.

    CBC, CMP, and urinalysis may aid in monitoring for infection, acidosis, and renal failure.

  • Drug Overdose/Poisoning

    A CBC, CMP, creatine kinase, urinalysis, lactate, and arterial blood gas should be obtained in all patients suspected of serious drug overdose/poisoning.

    Glucose should be checked at bedside for all patients.

    Serum alcohol level, and urine and serum toxin screens should be conducted.

    Serum acetaminophen and salicylate levels.

    A routine blood smear may show evidence of heavy metal toxicity (basophilic stippling, hemosiderosis).

    If heavy metal poisoning is being considered, a heavy metal screen should be performed.

    An EKG and cardiac enzymes may be obtained in patients suspected of sympathomimetic overdose or are showing signs of withdrawal from alcohol, benzodiazepines, or opiate if they complain of chest pain or a history is unable to be obtained.

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

  • Hypothermia is diagnosed by a core body temperature below 36 °C (96.8 °F). It is further classified as mild (34 °C-36 °C), moderate (30 °C-34 °C) and severe (<30 °C).

  • Hyperthermia is diagnosed by a highly elevated core body temperature usually 104 °F or greater in the absence of infectious, inflammatory, vascular, or autoimmune causes of fever.

  • Drowning is diagnosed in survivors of prolonged submersion in water.

  • Burns/Electrical Injury/Radiation Injury is diagnosed by a history of recent injury from heat, electricity, or radiation.

  • Stinging Insect Hypersensitivity is diagnosed by a hypersensitivity reaction immediately following a sting.

  • Carbon monoxide poisoning is diagnosed by symptoms and an elevated level of serum carboxyhemoglobin above 2% in a non-smoker and above 9% in a smoker.

  • Smoke inhalation is diagnosed from history, evidence of mucosal injury, and acute respiratory distress in a patient recently exposed to smoke.

  • Drug Overdose/poisoning is diagnosed through confirmatory blood or urine tests that show highly elevated levels of the substance.

D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.


III. Management while the Diagnostic Process is Proceeding.

A. Management of Clinical Problem Environmental Exposures.

  • Hypothermia

    For mild hypothermia (34 °C-36 °C) patients who are not in cardiac arrest, passive warming with blankets is recommended. For those with cardiac arrest, perform CPR as per ACLS protocol.

    For moderate hypothermia (30 °C-34 °C) patients not in cardiac arrest, begin active core rewarming. For those with cardiac arrest, defibrillation or pacing may be attempted as recommended. The intravenous medications should be spaced at longer intervals during resuscitation as they can reach toxic levels due to reduced metabolism.

    For severe hypothermia (<30 °C) in patients not in cardiac arrest, begin active core rewarming. For those with cardiac arrest, attempt defibrillation only once and withhold medications until the temperature is greater than 86 °F.

    Resuscitation should continue until the core body temperature is at least 32 °C or greater before death is declared in any hypothermic patients. If the potassium level is >12 mmol/L, then termination of CPR can be considered.

    All malnourished patients, including alcoholic patients, should receive thiamine to prevent Wernicke’s encephalopathy that may develop with rewarming.

    If sepsis is suspected, begin broad spectrum intravenous antibiotics.

    If adrenal crisis is suspected, administer intravenous corticosteroids immediately.

    If myxedema coma is suspected, do not use active warming methods at this may worsen hypotension and hemodynamics. Corticosteroids should be administered before levothyroxine.

    Active core rewarming can be achieved by giving warm fluids for resuscitation, surface cooling, and/or invasive cooling (using catheters).

    ECMO should be considered if a patient has hypothermia with cardiac instability and fails to respond to medical management.

  • Hyperthermia

    Discontinue any potential causative agents.

    Apply ice packs to neck, axilla, and groin.

    Consider evaporative cooling – spraying the naked patient with water or alcohol and having fans blown across the patient.

    If available, consider cooling blankets.

    If bacterial meningitis is suspected, begin appropriate intravenous antibiotics and perform lumbar puncture.

    See chapter on hyperthermia for details regarding specific therapy once the underlying cause is determined.

  • Drowning

    The first priority is to follow basic drowning life support (BDLS) and advanced drowning life support (ADLS) protocols.

    Priority should be given to obtain oxygenation and ventilation while CPR is being done. Resuscitation should continue until the core body temperature is at least >34oC before death is declared.

    Hospital care is recommended for grades 2 to 6. Grade 3 to 6 patients should be admitted to the ICU. Grade 2 patients can be observed in the emergency room for 6-24 hours. Grade 1 and rescue patients without any complaints or trauma can be discharged home.

    Grade 4-6 patients most often require mechanical ventilation. Management is similar to ARDS except that permissive hypercapnia should be avoided.

    CPAP can be used in grade 3 patients if the level of consciousness allows it.

    The most important complication after the episode is hypoxic-ischemic injury to the brain.

  • Burns/Electrical Injury/Radiation Injury

    The first priority is to follow basic life support (BLS) and advanced cardiac life support (ACLS) guidelines until the patient is hemodynamically stable.

    Active intravenous fluid resuscitation with normal saline or lactated Ringer’s is essential using the modified Brooke formula.

    Surgical consultation for debridement, fasciotomy, escharotomy, and wound closure if the degree of injury is moderate to severe. Decompression should be done when compartment syndrome is suspected.

  • Stinging Insect Hypersensitivity is diagnosed by a hypersensitivity reaction immediately following a sting.

    Follow basic life support (BLS) and advanced cardiac life support (ACLS) guidelines.

    If the patient has anaphylaxis, administer aqueous epinephrine 1:1000 dilution (1mg/mL), 0.2 mL to 0.5 mL intramuscularly or subcutaneously every 5 minutes, as necessary, to control symptoms and hypotension.

    If the patient has anaphylaxis, administer supplemental oxygen.

    If the symptoms are mild and there is no evidence of hemodynamic or respiratory compromise, 4-6 hours of observation usually suffices prior to discharge.

  • Carbon Monoxide Poisoning

    The first priority is to follow basic life support (BLS) and advanced cardiac life support (ACLS) guidelines AND

    Administer 100% oxygen by tight-fitting high-flow reservoir face mask (non-rebreather) or endotracheal tube until the patient is symptom-free.

    Consider hyperbaric oxygen – if COHb >25%-30%, cardiovascular compromise (infarction or dysrhythmia), severe metabolic acidosis, transient or prolonged loss of consciousness, neurologic injury.

    Hyperbaric oxygen is the treatment of choice for pregnant women.

  • Smoke inhalation

    The first priority is to follow basic life support (BLS) and advanced cardiac life support (ACLS) guidelines until the patient is hemodynamically stable.

    Ensure supplemental oxygen is being administered.

    Administer bronchodilators (inhaled beta-2 agonists (e.g., albuterol), inhaled anti-cholinergics (e.g., ipratropium). Steroids do not have any benefit.

    Early intubation should be considered in the presence of altered mental status, posterior pharyngeal edema, full-thickness nasolabial burns, circumferential neck burns, stridor/hoarseness, and CO poisoning.

    Administer suction of mucosal debris and secretions. Early bronchoscopy can help.

    Intravenous fluid resuscitation with isotonic fluids (e.g., normal saline).

  • Drug Overdose/poisoning

    The first priority is to follow basic life support (BLS) and advanced cardiac life support (ACLS) guidelines until the patient is hemodynamically stable.

    If the patient is comatose or convulsing, administer thiamine first followed by dextrose.

    Naloxone, 0.4-2 mg intravenously can be used for opioid induced respiratory depression.

    For hypotensive patients, intravenous boluses (>500 mL) of 0.9% normal saline should be administered. For patients that do not respond to intravenous fluids, consider norepinephrine 5-15 mcg/kg/min intravenous infusion. Glucagon should be considered early and is given at a dose of 10 mg over 10 min followed by 1 to 3 mg/hr.

    For hypertensive patients with symptoms of end organ dysfunction or a diastolic blood pressure greater than 110 mmHg, consider intravenous labetalol (10-20 mg) and lorazepam (1-3 mg if agitated). For persistent uncontrolled hypertension in this setting, nicardipine infusion (5-15 mg/hr) or nitroprusside sodium (0.25-8 mg/kg/min IV) can be considered. For patients with hypertension and cardiac chest pain, consider intravenous nitroglycerin (5-200 mcg/min, start 5 mcg/min q3-q5 min until response or dosage reaches 20 mcg/min, then increase by 10-20 mcg/min q3-5 minutes until response achieved).

    Activated charcoal can be administered to the alert patient after a massive oral ingestion of carbamazepine, dapsone, phenobarbital, quinine, or theophylline. Do not administer to a comatose or convulsing patient due to risk of aspiration.

    Gastric lavage can be considered if activated charcoal is not available for massive pill overdose if begun within 60 minutes of ingestion.

    Administer n-acetylcysteine for acetaminophen overdose. Follow nomogram.

    Urine alkalinization should be considered in salicylate poisoning.

    Skin decontamination is indicated in dermal exposures, especially in OP poisoning. Continuous infusion of pralidoxime (2PAM) should be considered in OP poisoning.

B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.

  • Hypothermia

    Hypothermic patients should not be declared dead until their core body temperature reaches 32 °C (89.6 °F).

  • Hyperthermia

    Caution with use of cold water baths because of the risks it introduces during resuscitation efforts, such as CPR or cardioversion.

    Acetaminophen and NSAIDs have little to no efficacy in a patient with hyperthermia.

  • Burns, Electrical injury, Radiation exposure, AND Smoke inhalation

    Intravenous fluid resuscitation is key because these patients tend to have a significant degree of third-spacing.

  • Drug Overdose/Poisoning

    The use of flumazenil for benzodiazepine overdose is generally not recommended.

    Many recreational drug users may ingest or inject more than one type of drug with opposing properties (uppers and downers).

IV. What's the evidence?

Epstein, E, Anna, K. “Accidental hypothermia”. BMJ. vol. 332. 2006. pp. 706-709.

Bierens, J. “Handbook on drowning: Prevention, rescue and treatment”. 2006.

“Centers for Disease Control and Prevention (CDC). Clinical guidance for carbon monoxide (CO) poisoning after a disaster”.

Vassal, T, Benoit-Gonin, B, Carrat, F, Guidet, B, Maury, E, Offenstadt, G. “Severe accidental hypothermia treated in an ICU: prognosis and outcome”. Chest. vol. 120. 2001. pp. 1998-2003.

Mallet, M. “Pathophysiology of accidental hypothermia”. QJM. vol. 95. 2002. pp. 775-785.

O’Grady, N. “Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from American College of Critical Care Medicine and the Infectious Disease Society of America”. Crit Care Med. vol. 36. 2008. pp. 1330-1349.

Martinez, M. “Drug-associated heat stroke”. South Med J. vol. 95. 2002. pp. 799-802.

Mokhlesi, B, Leikin, J, Murray, P, Corbridge, T. “Adult toxicology in critical care: Part II: specific poisonings”. Chest. vol. 123. 2003. pp. 897-922.

Freeman, T. “Hypersensitivity to hymenoptera stings”. NEJM. vol. 351. 2004. pp. 1978-1984.

Bierens, J, Knape, J, Gelissen, H. “Drowning”. Curr Opin in Crit Care. vol. 8. 2002. pp. 578-86.

Koumbourlis, A. “Electrical Injuries”. Crit Care Med. vol. 30. 2004. pp. 5424-5430.