2015 PEM Boards: Napo Flashcards
Cholinergic poisoning
“SLUDGE” (salivation, lacrimation, urination, diarrhea, gastric emesis)
DUMBBBBELS: Diarrhea, Urination, Miosis, Bradycardia, Bronchorrhea, Bronchospasm, Bradypnea, Emesis, Lacrimation, and Sialorrhea (drooling) are common physical findings.
-due to irreversible inhibition of acetylcholinesterase and excess acetylcholine at the neuromuscular junction
-resulting overstimulation of cholinergic receptors
-Organophosphate exposure
-mainstay of stabilization and treatment for cholinergic poisonings is the administration of atropine
-An easy way to remember which antidote is needed is: if wet (bronchorrhea, diaphoresis, sialorrhea), give atropine, which helps to dry secretions; if weak (fasciculations, weakness, paralysis) give pralidoxime, which will help protect nicotinic skeletal muscle receptors.
Tetanus Tx for un immunized child
TIG +
Tdap, Td, or TT if >7yo
DTaP if 6weeks-6years
Atropine
competes with acetylcholine at the cholinergic receptors
-classified as an anticholinergic drug = antimuscarinic
-competitive antagonist for the muscarinic acetylcholine receptor
-decreases the muscarinic cholinergic effects
-Atropine is given as a treatment for SLUDGE
Pralidoxime aka “2-PAM” = acetylcholinesterase reactivating agent → treats SLUDGE
-“hot as a hare, blind as a bat, dry as a bone, red as a beet, and mad as a hatter”
Physostigmine
agent that may be used in significantly symptomatic anticholinergic (atropine) poisonings
Jimson weed
causes anti-cholinergic effects
causes atropine toxidrome
Asystole or PEA (PALS)
CPR
Epi 0.01 mg/kg (0.1 mL/kg of 1:10,000)
Bradycardia (PALS)
CPR if HR <60
Epi 0.01 mg/kg
Atropine 0.02 mg/kg
Pace em
Tachycardia (PALS)
Unstable = synchronized cardioversion 0.5-1J/kg then 2J/kg
Adenosine 0.1 mg/kg then 0.2mg/kg
Amiodarone 5mg/kg
Malignant hyperthermia
Tx?
Cause?
Treat malignant hyperthermia with dantrolene
sux is usually the offending agent
VFib/Pulseless VT
Defibrillate @ 2J/kg then 4J/kg
then try epi 0.01mg/kg
NMS
Tx?
Cause?
Treat neuroleptic malignant syndrome with bromocriptine (antpsychotics are offenders)
serum osmolality formula
serum osmolality = (serum Na x 2) + (serum glucose/18) + (BUN/2.8)
-elevated osmolar gap= > 10
Metabolic abnormality of Pyloric Stenosis
pyloric stenosis = hypokalemic, hypochloremic metabolic alkalosis due to loss of gastric acid (which contains hydrochloric acid and potassium)
winter’s formula?
P CO2 = (1.5xHCO3)+8+/-2
-used to evaluate respiratory compensation when analyzing acid-base disorders and a metabolic acidosis is present
Fatty Acid Oxidation Disorder
- Hypoglycemia with absence of ketones in urine indicates a problem with mitochondrial oxidation of fatty acids
- MCAD is the most common form
- have low plasma carnitine levels on a acylcarnitine profiles
- high levels of urinary organic acids
- Test with Plasma acylcarnitine profile
- Treat with avoidance of fasting and perhaps carnitine supplementation.
- acidosis with no ketones
Organic acidemia
- disorder involving the metabolic pathway in degradation of the organic amino acids valine, leucine, and isoleucine
- Results in buildup of intermediate organic acids causing profoundly high anion gap metabolic acidosis.
- Presents with lethargy, poor feeding, and convulsions.
- Elevated ammonia levels occur as a result of inhibition of the urea cycle enzymes from the Organic acidemia.
- elevated ammonia levels but not as high as primary urea cycle disorders.
- Also have thrombocytopenia.
- acidosis +ketones
- Maple syrup urine disease is an example
Primary urea cycle disorders
- eg. OTC deficiency
- present with extremely high ammonia levels and encephalopathy with ataxia
- presents during periods of stress or from exposure to a high-protein diet.
- Not associated with metabolic acidosis and will have normal lactate levels, differentiating this from organic acidemia.
- BUN is also typically very low.
- ARGININE ADMINISTRATION IS BENEFICIAL IN THE TREATMENT OF ELEVATED AMMONIA DUE TO UREA CYCLE DISORDERS
- Sodium benzoate and phenylacetate are other agents that can be used for elevated ammonia levels from any cause; they can be added to the regimen to facilitate excretion.
- If that doesn’t work → hemodialysis. Think about it when they say “clumsy” or encephalopathy.
glutaric aciduria Type 1 (GA1)
- inborn error of metabolism most consistent with the presentation of macrocephaly, chronic subdural effusion with an acute decompensation
- caused by a deficiency of glutaryl-CoA dehydrogenase, required in the breakdown of hydroxylysine, lysine, and tryptophan.
- Unlike other organic acidurias, GA1 rarely manifests in the newborn period.
- The diagnosis is usually made during crises, such as intercurrent illnesses, in which patients may present with metabolic acidosis, hyperammonemia and encephalopathy. -Macrocephaly is a common finding in GA1, with 30% associated with subdural effusions. Minor trauma will often lead to acute intracranial bleeding.
- Urine reducing substance and uric acid are expected to be normal.
- Test with urine organic acids.
typical dextrose infusion rate
6-8mg/kg/min
Galactosemia
- excretion of reducing substances in urine due to galactose-1-phosphate uridyltransferase deficiency.
- Will have elevated direct bilirubin.
- High association with cataract formation.
- High association with E. coli sepsis.
Glycogen storage disorder
–presents with lactic acidosis, hepatomegaly, and hypoglycemia.
-Normal ammonia level differentiates this from organic acidemias
Charcot’s triad
= acute ascending cholangitis
= is RUQ pain, jaundice and high fever
-occurs when a gallstone blocks the common bile duct (choledolithiasis) and an infection occurs
Intussusception in patient with HSP
- the most common type is ileal – ileal.
- Because of this, CT scan has better sensitivity for small bowel intussusception, rather than ultrasound
the most lethal of malarias is?
Plasmodium faciparum
the only ototopical antibiotic approved for use with a perforated tympanic membrane is?
Ofloxacin
the first sign of radiation damage is???
Lymphopenia
To decrease intraocular pressure…
- topical beta blockers
- topical alpha adrenergic agonists
- mannitol
- carbonic anhydrase inhibitors (not to be used in patients with sickle cell disease because it decreases the pH and promote sickling)
depolarizing agent?
Succinylcholine
nondepolarizing agent?
Rocuronium
Heat stroke is defined by????
- temperature greater than 104°
- in association with any CNS abnormalities.
- Treat with ice water emersion initially.
- Antipyretics are not indicated.
A pseudo-Jones fracture is???
a fracture at the base of the fifth metatarsal
Jones fracture is???
a fracture of the diaphysis of the fifth metatarsal
Lisfranc injury is???
typically result from fracture or dislocation of the second metatarsal
Guillan Barre Syndrome Features
- Acute peripheral neuropathy
- Loss of deep tendon reflexes
- Ascending paralysis
- There may be autonomic instability with labile blood pressure.
- Cranial nerve involvement, especially VII, may be seen, and a CT scan of the brain without contrast, if obtained, will be normal.
- Classic CSF findings include elevated protein, WBC <10, and normal glucose.
- Negative inspiratory force is best to monitor for respiratory muscle involvement.
- More recent studies indicate steroids may not be helpful, and may prolong recovery.
Botulism Features
- Presents with cranial nerve involvement
- Weakness spreads to trunk and extremities
- Deep tendon reflexes and sensation is intact
Treatment of methanol toxicity?
Fomepizole inhibits alcohol dehydrogenase preventing formation of formic acid which is toxic. It is used for methanol ingestions. Hemodialysis is mandatory in methanol ingestions if there is acidosis.
Erythema infectiosum?
= fifth disease
= slapped cheek
Roseola infantum
=exanthema subitum
= fever for several days and as the patient defervesced they develop a rash
Decompression sickness features?
- no barotrauma required
- LOC is rare
- occurs after >10 minutes
- treat with hyperbarics
- CXR is essential prior to transportation to a hyperbaric chamber; a small pneumothorax, if unrecognized, can become a large tension pneumothorax during recompression/decompression therapy. Recognizing a pneumothorax and placing a chest tube would be required prior to hyperbaric treatment.`
Arterial gas embolism features?
- LOC is common,
- occurs within the first 10 minutes
- can result from barotrauma
Burn factors that should prompt consideration for referral include:
1) partial thickness depth >10% if 20% BSA > 11 years)
2) full thickness depth > 2% BSA
3) high risk for disability or poor cosmetic outcome (e.g., hands, feet, face, circumferential burns and those overlying joints)
4) associated inhalation injury or trauma.
TCA toxidrome
- ie amitriptyline
- causes alpha-adrenergic receptor inhibition
- QT prolongation secondary to potassium channel blockade
- PR and QRS prolongation and bradycardia are secondary to sodium channel blockade
Which chemical eye injury sucks the most?
Alkali chemical injuries to the globe are worse than acid
-Irrigation takes priority; irrigate to a pH of 7-7.5
Hyphema management
Hyphema = Blood in the anterior chamber
- High risk of rebleeding (30%)
- Management is maintaining the head of the bed at 30° or greater, dilation with cycloplegics (ie homatropine) , decreasing the intraocular pressure using mannitol, carbonic anhydrase inhibitors, topical beta blockers, or topical of adrenergic agonists
Plastibell should fall off when????
after 3-7 days
Bloody infectious diarrhea causes???
Campylobacter Escherichia coli Salmonella, Shigella -Consider treatment for shigella with Azithromycin (increasing Bactrim resistance)
Transverse myelitis features
- Flaccid paralysis
- weakness
- loss of reflexes
- dx with mri
Lyme disease treatment
> 8 years of age treat with 4 weeks of doxycycline
<8 years of age treat with amoxicillin for 4 weeks
permanent upper tooth eruptions age range
- central incisors at 7 to 8 years
- lateral incisors at 8 to 9 years
- cuspids at 11 to 12 years
- first bicuspids at 10 to 11 years
- second bicuspids at 10 to 12 years
- first molars at 6 to 7 years
- second molars at 12 to 13 years
- third molars at 17 to 21 years.
Oh sh!t……impending herniation!!!!
- intubation via RSI, with hyperventilation, is first priority for lowering ICP in patients with impending herniation.
- Hyperosmolar therapy can help decrease ICP in the emergently deteriorating patient.
- Immediate administration of mannitol at dose of 0.25 to 1 gram/kg; blood pressure should be carefully monitored to avoid hypotension.
- Hypertonic saline 3% is an alternative to mannitol, but its infusion rate is 0.1 to 1 ml/kg per hour. (or 6ml/kg bolus)
Myocarditis on ECG
Sinus tachycardia with low-voltage QRS complexes and inverted T waves
Pericarditis on ECG
Widespread ST elevation, PR depression, ST elevation in limb and precordial leads. The elevations are concave.
Blunt or penetrating neck injury imaging????
Conventional Angiography is the gold standard for penetrating neck injury; CTA is another option if HDS
Cushing’s triad
- bradycardia (first sign you’ll usually see)
- hypertension
- irregular respirations
- associated with increased intracranial pressure.
What is a positive DPL finding?
-free aspiration of gross blood, gastrointestinal contents, vegetable fibers or bile through the lavage catheter upon entering the abdominal cavity
or the presence
- ≥100,000 RBC/mm3
- ≥500 WBC/mm3
-bacteria on Gram stain of the lavage fluid.
What is a Chance fracture?
Chance fractures of the lumbar vertebrae (transverse fracture and anterior compression fracture of the vertebral body)
Kehr’s sign????
- pain radiating to the left shoulder from diaphragmatic or phrenic nerve irritation
- may be a presenting sign of acute splenic injury and can persist in the days to weeks following injury
“acceptable allowances” in angulation for distal radius buckle fractures
- up to 15 degrees for children less than 8 – 10 years of age
- up to 10 degrees of angulation for those over 10 years of age
“allowances” in volar angulation in metacarpal neck fractures
early closed reduction should be considered when there is:
a) > 10 degrees of angulation in the 2nd and 3rd mMCPs
b) > 20 degrees of angulation in the 4th MCP
c) > 30 degrees of angulation in the 5th MCP
Ulnar nerve →
- motor function includes wrist flexion, finger spreading and power grasping
- supplies sensory innervation to the entire 5th finger and to the ulnar aspect of the 4th finger (in 90% of people)
Median nerve →
- also involved in wrist flexion
- but would be tested by flexion at the PIP joints and opposition of thumb and 5th finger
- its sensory innervation includes the 1st, 2nd, and 3rd digits as well as the radial aspect of the 4th (in 90%)
Anterior interosseous nerve →
- a branch of the median nerve
- involved in flexion of the distal phalanges of all 5 digits
- tested by making an “okay” sign with the thumb and index finger
- has no sensory function
Radial nerve →
-involved in wrist extension and supplies sensation to the radial aspect of the dorsum of the hand.
Foxglove and oleander toxidrome
- contain cardiac glycosides and behave like digoxin
- inhibiting the Na+-K+- ATPase pump
- causing GI symptoms, and, in severe cases, cardiac dysrhythmias
Oral chelation treatment approved for childhood lead poisoning and is recommended for lead levels between 20 and 70 µg/dL?????
oral DMSA
chelation treatment for lead levels over 70 µg/dL???
Combination EDTA and BAL are given IV and IM, respectively
SLE ECG will demonstrate changes of????
epicardial inflammation with:
- widespread ST elevation
- PR depression
- ST elevation in limb and precordial leads (elevations are concave)
black widow spider antivenin indications????
Lactrodectus mactans antivenin indications include:
1) age < 5 years
2) respiratory difficulty
3) hypertension
4) persistent pain despite appropriate IV analgesics
Copperhead Antivenom is indicated for the progressive effects of the venom, including: ???
1) worsening local injury (pain, swelling, and ecchymosis)
2) coagulopathy
3) systemic effects (hypotension and altered mental status).
What do Catfish, Sea urchin, and sting ray envenomations have in common????
-heat labile toxin, which is best treated with immediate immersion into hot water (T 45ºC)
brown recluse spider bite features
Loxosceles = = bites most commonly cause local skin reactions (pain, erythema, blister), which may progress to ulcerative necrosis.
- Systemic reactions are rare, and are more often noted in small children 1-2 days after the bite
- symptoms include fever, chills, malaise, weakness, nausea, vomiting, joint pain, petechial morbilliform rash, intravascular hemolysis, hematuria, and renal failure → hyperkalemia
Scombroid poisoning
- aka histamine fish poisoning
- MC seen after ingestion of spoiled “oily fish,” such as tuna, mackerel, and bonito
- Histidine is converted by histidine decarboxylase to histamine by a variety of microorganisms in these fish.
Pufferfish poisoning
- contain tetrodotoxin, which is a neurotoxin.
- causes oral paresthesia and numbness, dizziness, nausea, vomiting, hypotension, generalized muscle paralysis with ensuing respiratory failure due to paralysis of the diaphragm.
Ciguatera fish poisoning
- most commonly reported marine toxin disease in the world
- found in contaminated reef fish: barracuda, grouper, and snapper
- symptoms: gastrointestinal (diarrhea, abdominal cramps and vomiting), neurologic (paresthesias, pain in the teeth, pain on urination, blurred vision, and temperature reversal) and cardiovascular (arrhythmias and heart block).
- Treatment is symptomatic, including IV fluids, anti-emetics, and management of arrhythmias
- important to avoid opioid therapy; opioids may interact with maitotoxin, one of the biotoxins responsible for ciguatera poisoning, and the combination may lead to the development of hypotension.
Sting from a jellyfish
mainstay of treatment is:
1) relief of pain (with morphine in this case);
2) alleviation of venom effects
3) control of shock.
- irrigation with seawater or normal saline is recommended
- Irrigation with either hot or cold tap water increases risk of additional nematocyst discharge. Causes N&V.
Serotonin Toxicity (ST), formerly called Serotonin Syndrome
- can be effectively treated with cyproheptadine, a 5HT2 receptor antagonist
- classic features= autonomic instability (notably HR and BP variability), ocular clonus, diaphoresis, hyper-reflexia, spontaneous extremity clonus but lack of leadpipe rigidity, as seen with Neuroleptic Malignant Syndrome (NMS).
- history of the use of an antidepressant citalopram and concomitant use/abuse of dextromethorphan in cough syrup is a classic drug-drug interaction of a serotonin reuptake inhibitor (SSRI) and dextromethorphan, which also functions in serotonin reuptake inhibition.
Essential criteria for NMS
- includes recent use of dopamine blocking drug (usually an anti-psychotic medication)
- muscular rigidity
- CK > 1000 U/L
- temperature elevation > 38ºC
- Bromocriptine is a dopamine receptor agonist used in the treatment of NMS.
Tricyclic Antidepressant (TCA) overdose
- wide complex tachycardia
- increased QRS and QTc intervals
- hypotension
- Sodium bicarbonate is useful in tricyclic antidepressant toxicity, as well as overdoses of other sodium channel blocking drugs. Overcomes the channel blockade is the primary mechanism; alkalinization also results in increased protein binding of TCAs so there is less free drug to exert toxicity.
- Can also alkalinize by hyperventilation while awaiting sodium bicarbonate infsuion.
One-pill kill medications include???
- opioids
- cardiovascular medications such as CCBs, BBs, and antidysrhythmics (procainamide, flecainide, quinidine, disopyramide)
- antidepressants (in particular tricyclic antidepressants)
- antipsychotics (especially older phenothiazines such as thioridazine, chlorpromazine, etc.)
- older antimalarials (chloroquine, hydroxychloroquine).
Anti-HBs means????
Anti-HBs means vaccination
Earliest IgM detector of Hep B infxn?
IgM Anti-HBc
- even b4 HBsAg is detectable
oral standard for non-resistant malaria organisms
- chloroquine with doxycycline or sulfadoxine-pyrimethamine
- Quinidine can be given IV if the patient is ill
- Chloroquine-resistant strains can be treated instead with quinine plus sulfadoxine-pyrimethamine or atovaquone-proguanil
Hallmark of malarial infection
Usual laboratory features include a low or normal WBC with thrombocytopenia
Parkland Formula
Fluid Requirements = TBSA burned(%) x Wt (kg) x 4mL
-Give 1/2 of total requirements in 1st 8 hours, then give 2nd half over next 16 hours
Rule of 9’s for Adults
9% for each arm 18% for each leg 9% for head 18% for front torso 18% for back torso
Rule of 9’s for Children
9% for each arm 14% for each leg 18% for head 18% for front torso 18% for back torso -child’s palm and fingers as an estimate of 1% BSA
Lido NO epi toxicity
4.5-5 mg/kg
Lido + Epi toxicity
7 mg/kg
Human bites are at risk of infection by???
Eikenella corrodens, Staphylococci, Streptococci, and oral anaerobes including Bacteroides species.
Cat bites & puncture wounds should be left open, and patients provided prophylaxis against???
Pasteurella multocida, Staphylococcus, Streptococcus, and Bacteroides species (e.g., amoxicillin-clavulanic acid).
propofol is contraindicated with???
egg and/or soy allergies
ketamine is relatively contraindicated when???
there is a history of psychosis
nitrous oxide is contraindicated???
in a patient with trapped gas pockets—as would be the case with an otitis media, pneumothorax, or bowel obstruction
inotropic support for heat stroke???
- Dobutamine
- increase myocardial contractility while maintaining peripheral vasodilation(b/c its pure beta adrenergic).
- Chilled IVFs may lower body temperature, but could precipitate an arrhythmia so should be avoided.
- No tylenol, ibuprofen, epi, or atropine either.
prophylactic of choice for Acute Mountain Sickness
-acetazolamide
Electrolyte findings in bullimia
hypokalemia hypomagnesemia hypochloremic alkalosis Serum amylase often elevated QT and T-wave changes are often observed on ECG
NMS features
- complication of antipsychotic treatment presumably caused by blockade of the dopaminergic pathways in the basal ganglia and hypothalamus
- Autonomic dysregulation leads to hyperthermia, urinary incontinence, diaphoresis, tachycardia and labile BP.
- Symptoms = motor rigidity, akinesia, mutism, and agitation. -Treatment involves starting the muscle relaxant dantrolene, often together with the post-synaptic dopamine receptor agonist bromocriptine (Parlodel®) or the pre-synaptic dopamine receptor agonist amantadine.
What drugs increase lithium levels????
- NSAIDs
- Thiazide diuretics
- ACE inhibitors
NMS treatment???
dantrolene
bromocriptine = post-synaptic dopamine receptor agonist
amantadine = pre-synaptic dopamine receptor agonist
Ricin
- potent toxin(can cause resp failure in 6 hours)
- derived from the beans of the castor plant
- inhalation –> fever, chest tightness, cough, dyspnea, nausea, and arthralgias.
- Progress to cyanosis, pulmonary edema and resp failure
- symptoms in hours vs days as in anthrax or plague
Cutaneous anthrax: Features and treatment?
- papule → vesicle → eschar.
- Antibiotics of choice include ciprofloxacin and doxycycline
Bubonic plague
Cause?
Presentation?
- due to an infected flea bite.
- Clinical manifestations include the onset of painful unilateral swelling with malaise, high fever and abdominal pain.
- Bubonic plague can quickly progress to septicemic plague with spread to the lungs and CNS.
- Black necrotic and purpuric lesions can appear with the septicemic form.
Pneumonic plague: Cause? Presentation? CXR? Treatment?
- caused by Yersinia pestis, a rod shaped non-motile Gram-negative coccobacillus.
- The initial presentation includes respiratory symptoms, fever, cough and myalgia. The clinical course is rapidly progressive with bloody sputum, dyspnea, cyanosis, circulatory collapse and a bleeding diathesis.
- CXR shows bilateral patchy infiltrates.
- Treatment of choice is streptomycin. Alternative therapy includes gentamicin or doxycycline.
- Those in contact with a patient suspected of pneumonic plague should be treated with doxycycline for 7 days or during risk of exposure.
- will have bloody sputum while anthrax does not
Tularemia
Cause?
Presentation?
Tx?
- caused by the Gram-negative coccobacillus F. tularensis.
- Symptoms can be mild and present with nonspecific symptoms such as fever, malaise and pneumonia.
- If one suspects tularemia, streptomycin, gentamicin, doxycycline, and ciprofloxacin have been proven to be effective.
- Many forms from Ulceroglandular → oculoglandular → to pneumonic.
Cyanide poisoning
- causes cellular anoxia.
- Low concentrations can cause headache, light-headedness, nausea and ataxia.
- Classic symptoms include respiratory distress, cherry red skin and bitter almond odor. Patients can also develop unconsciousness, seizures, bradycardia, arrhythmias and hypotension progressing to cardiac arrest.
- Management includes airway and circulatory support, correction of metabolic acidosis and seizure control.
- Antidotes include amyl nitrate or sodium nitrite.
- there’s no cyanide test
- presents with elevated lactate and anion gap acidosis; combined with a reduced arterial-venous oxygen saturation difference (< 10%) suggests diagnosis
- Administer hydroxocobalamin (Cyanokit) or the Cyanide Antidote Kit if a diagnosis of cyanide toxicity is strongly suspected.
- Hydroxocobalamin combines with cyanide to form cyanocobalamin (vitamin B-12), which is renally cleared. The Cyanide Antidote Kit contains amyl nitrite pearls, sodium nitrite, and sodium thiosulfate.
Smallpox
- can present with symptoms of malaise, fever, vomiting, and headache.
- 15% of patients can present with delirium.
- Two to three days later skin lesions can appear. They quickly progress from macules to papules to pustular vesicles. The rash appears more concentrated on the extremities and face in a centrifugal distribution and develop synchronously.
- strict isolation and public health officials should be notified. Those in contact should also be placed in strict quarantine for 17 days.
FDA approved as the antidote for internal contamination of cesium exposures?
Prussian Blue
Indicated for a nuclear power accidents.
Potassium iodine is indicated in the exposure of radioactive iodine.
Used for the treatment of anthrax and plague?
Ciprofloxacin
Used in the treatment of methemoglobinemia?
Methylene blue
Methemoglobinemia (MetHgb): Features? Causes? Dx? Antidote?
- cyanotic appearance without underlying cardiac or pulmonary disease
- will look diffusely gray to cyanotic in color with a pOx reading 85% or more
- Supplemental oxygen will not alter the color (an indication the cyanosis is not a primary pulmonary process)
- MetHgb can occur via acquired (medications ie Benzocaine, oxidative stress, dehydration, sepsis, chemicals) or congenital causes
- best diagnosed with a CO-oximeter, a device that uses spectrophotometry to measure relative blood concentrations of oxyhemoglobin, carboxyhemoglobin and MetHgb.
- when placing a drop of blood on filter paper, the blood will maintain a chocolate brown color if MetHgb is present.
- 1 mg/kg methylene blue can be used as an antidote
Compartment syndrome Dx?
- Pressures >30 mmHg are generally considered diagnostic. -not the case in hypotensive patients where CS can occur at lower pressures.
- pressures exceeding 30 mm Hg or within 30 mm Hg of the patient’s MAP are an indication for fasciotomy
Pleural fluid levels indicative for exudative (as in pneumonia or empyema) are ???
- WBC > 10,000/mm3
- glucose < 50% of serum glucose
- amylase > 200 IU/L
- protein/serum protein > 50% of serum protein
- LDH > 60% of serum LDH
- Pleural fluid pH < 7.0 and amylase > 200IU/L suggests empyema
What is Phosgene?
- toxic inhalant agent that causes respiratory symptoms.
- “newly mowed hay”
What does sarin do?
- Nerve agent
- potent inhibitors of acetylcholinesterase and would also have effects on the CNS system and muscarinic receptors.
- causes cholinergic→ SLUDGE
What produces dermal damage as initial presenting symptoms?
Vesicants (Lewisite)
Management of electrical injury + loss conciousness?
= admit for cardiac monitoring
Treatment for CAH crisis?
-stress dose of hydrocortisone (25-50 mg/m2 IV)
Conjunctivitis timing?
Chemical?
Gonorrhea?
Chlamydial?
- Chemical conjunctivitis (historically due to silver nitrate prophylaxis) appears in the first day of life and resolves in 2-4 days.
- Gonococcal conjunctivitis occurs 3-5 days after birth.
- Chlamydial conjunctivitis develops 5- 14 days after birth.
- Non-gonococcal, non-chlamydial bacterial conjunctivitis usually presents after first 2 weeks of life.
Lab findings in conjunctivitis?
- non-chlamydial bacterial?
- chlamydial?
- non-chlamydial bacterial conjunctivitis= Gram stain will show the offending bacteria and neutrophils.
- C. trachomatis, however, is an obligate intracellular parasite. As such, Gram stain reveals only neutrophils, lymphocytes, and/or plasma cells. A conjunctival scraping for DFA testing aids in the diagnosis of chlamydial conjunctivitis.
Spinal cord injury and neurogenic shock?
VS findings?
Why?
Management?
- Combination of hypotension and relative bradycardia unresponsive to crystalloid boluses
- neurogenic shock causes loss of sympathetic CV tone resulting in relative bradycardia and decreased cardiac contractility, as well as pooling of blood in the peripheral vascular bed.
- Sympathetic nerve fibers exit the spinal cord from C7-L1.
- Use of a combined α-adrenergic/β- adrenergic vasoactive such as norepinephrine
- selective α- adrenergic agent such as phenylephrine would be recommended in this situation.
“Tet spell”
Cause?
Effects of calming? squatting?
Tx?
- episodes occur due to transient increase in resistance to pulmonary blood flow with increased preferential deoxygenated blood flow to the body.
- Calming the child will decrease systemic venous return
- tucking in the knees or squatting will also increase systemic vascular resistance and thus allow for temporary reversal of the shunt.
- Morphine will also decrease systemic venous return and improve pulmonary blood flow.
- Phenylephrine is another useful agent used to increase systemic vascular resistance.
- Oxygen at 100% FiO2 may be effective since it is a potent pulmonary vasodilator and systemic vasoconstrictor, which will promote pulmonary blood flow.
- Propranolol is the long-term treatment of the spells but is not useful in acute episodes.
TCA toxicity What does it do? Symptoms? ECG? Tx?
- direct alphaadrenergic blockade, anticholinergic effects, and inhibition of norepinephrine and serotonin reuptake resulting in a blockade of fast sodium channels in myocardial cells.
- As a result, altered mental status, tachycardia, hypotension/hypertension and seizures may be presenting symptoms.
- ECG = sinus tachycardia with prolongation of the PR, QRS and QT intervals.
- Treatment of TCA toxicity involves serum alkalization.
- Elevated blood pH enhances the serum protein binding of TCAs, which will result in decreased serum concentrations of the unbound and pharmacologically active drug. This can be achieved via intubation of the patient with hyperventilation.
- IV sodium bicarbonate is another effective method of serum alkalization.
Lesions which will depend on flow via the ductus arteriosus to maintain systemic circulation and present as acute shock as the ductus closes are:(3)?
- coarctation of the aorta
- critical aortic stenosis
- hypoplastic left heart syndrome
Lesions which will depend on flow via the ductus arteriosus to maintain pulmonary circulation and present as acute cyanosis as the ductus closes are: (4)?
- critical pulmonary stenosis
- pulmonary atresia
- tricuspid atresia
- transposition of the great vessels.
Milrinone
Inidication?
Effects?
- cardiogenic shock and for support of BP by improving contractility and afterload reduction
- increases CO by improving systolic fnxn, diastolic relaxation, & decreasing SVR (w/o compensatory tachy)
What is Isoproterenol?
-an inotropic agent to increase cardiac output is indicated only if the HR is low.
example of CCB used to treat HOCM?
Diltiazem
HOCM Tx?
- beta-blockers and calcium channel blockers
- Beta-blockers decrease outflow obstruction and increase ventricular compliance
- CCBs work by 2 mechanisms: (1) improving diastolic filling through improving diastolic relaxation and 2) decreasing the outflow gradient by depression of cardiac contractility.
Rickets Calcidiol level? Calcium level? parathyroid hormone level? Alkaline phosphatase level?
= deficiency of Vitamin D
- Calcidiol (25-hydroxycholecalciferol) circulates in the plasma as the most abundant of the vitamin D metabolites and is thought to be a good indicator of overall vitamin D status.
- Will be decreased in Rickets.
- In the vitamin D deficient state, hypocalcemia develops, which stimulates excess parathyroid hormone, leading to renal phosphorus loss, further reducing deposition of calcium in the bone. Alkaline phosphatase levels increase as a result of overactive osteoblastic cell activity.
Treat central DI with???
- NS first before ddavp or vasopressin
PCOS
LH?
FSH?
Androgens?
= elevated LH, normal to low FSH, elevated androgens
thyroid storm tx?
- Give Potassium iodide PO
- Treat htn and tachy 2/2 thyroid storm with propranolol
- Iodides rapidly inhibits the release of thyroid hormone from the thyroid gland.
- PTU, which inhibits synthesis of thyroid hormone, was a first line agent, but due to its association with pediatric liver failure, it is now contraindicated in children.
- Methimazole inhibits iodine oxidation in the thyroid gland; however, its effects are minimally useful in the acute management because the reduction in thyroid levels may take several days.
Hypertensive emergency → treat with ???
→ Sodium nitroprusside is a very potent vasodilator and would be most appropriate. It has an immediate onset of action and its effects are present as long it is being infused. -Labetalol, a β- adrenergic blocker, can also be used in hypertensive emergencies but it has an onset of action of 5 minutes and is contraindicated in patients with asthma, heart block, or heart failure.
Varicella
prophylaxis?
tx?
- VZIG, given within 96 hours of a varicella exposure, may prevent or lessen the severity of illness.
- Acyclovir is indicated for patients with evidence of disease.
Wilms’ tumors symptoms
Hypertension is detected in about 25% at presentation
Physiologic anemia of infancy occurs???
- in term infants from 6 weeks to 3 months of age
Aplastic crisis vs ASSC
- acute drop in Hgb accompanied by reticulocytosis is concerning for ASSC
- Reticulocytopenia, absence of splenomegaly, and more gradual onset of symptoms seen in aplastic crisis help to distinguish this it from acute splenic sequestration crisis
Acute KD Tx?
Convalescent KD Tx?
- Acute KD → IVIG and high dose aspirin.
- KD in convalescent phase → treated with low dose aspirin.
Juvenile dermatomyositis (JDM)
- 2:1 male to female ratio
- present with proximal muscle fatigue, which often involves diaphragm and esophageal muscle activity.
- diffuse, photosensitive facial rash is present in 25% of patients. The rash includes the naso-labial folds, unlike the malar rash of systemic lupus erythematosus (SLE), which spares these folds.
- elevated are muscle-derived enzymes: ANA, aldolase, AST, ALT, LDH, and CPK.
- rash on metacarpals is Gottron’s sign and is diagnostic
Neonatal complications of SLE antibodies include???
- various forms of heart block
- hemolytic anemia
- thrombocytopenia
common side effect of several HIV medications???
Acute pancreatitis – check a lipase
hereditary angioedema = HAE
Deficiency?
Screening test?
- autosomal dominant disease
- caused by low plasma protein C1 inhibitor (C1-INH)
- Deficiencies in C1-INH allow unchecked activation of the classic complement pathway.
- painless, nonpruritic, nonpitting swelling of the skin; severe abdominal pain; or acute airway obstruction
- screening test for HAE is a serum C4 level, which is almost always decreased during attacks and is usually low between attacks.
- C3 and C1q are normal in patients with HAE
Test for acute HIV???
- with HIV RNA
- Confirm with Western Blot in 2-4 months
Pneumocystis carinii pneumonia (PCP) lab abnormality?
-high LDH
Pityriasis rosea
- selflimited & unclear etiology
- starts with “herald patch” (seen in the first picture) that can sometimes be confused with tinea corporis
- followed by “Christmas tree” pattern (running parallel to the ribs)
- thought by some to be caused by HHV-6
- Steroids, antibiotics, antifungals, and antivirals have not been shown to hasten the resolution of the rash.
Tinea versicolor
cause?
dx?
tx?
- caused by Malassezia furfur
- will fluoresce with Woods lamp
- tx with topical miconozole
Treatment of acute cerebral edema???
- reduction of fluids
- early IV mannitol (0.25-1.0 g/kg over 20 minutes)
- 3% hypertonic saline (5-10 mL/kg over 30 minutes)
Inhalational anthrax
- caused by Bacillus anthracis, a rod shaped Gram-positive sporulating organism
- fever, malaise, fatigue, cough and chest discomfort, headache, vomiting and diarrhea
- Widened mediastinum, with/without pleural effusions
- cannot be spread by respiratory or physical contact
- Prophylaxis of inhalation anthrax and for treatment of the fulminant respiratory disease is ciprofloxacin. Doxycycline can also be used.
Segmental (transection) syndrome
Clinical manifestations?
Causes?
- Clinical manifestations-loss of all sensory modalities, weakness below affected level; bladder dysfunction
- Causes: trauma, hemorrhage, epidural abscess, transverse myelitis, epidural metastases
Dorsal cord syndrome
Clinical manifestations?
Causes?
- Clinical manifestations: loss of proprioception, vibratory sensation; variable weakness and bladder dysfunction
- Causes: tabes dorsalis, Frederick ataxia, subacute combined degeneration, aids myelopathy, MS
Ventral cord syndrome (anterior spinal artery syndrome)
Clinical manifestations?
Causes?
- Clinical manifestations: loss of pain and temperature sensation, weakness, bladder dysfunction.
- Causes: spinal cord infarction, disc herniation, radiation myelopathy, HTLV–1
Brown Sequard Syndrome
Clinical manifestations?
Causes?
- Clinical manifestations: ipsilateral weakness and loss of proprioception; contralateral loss of pain and temperature sensation
- Causes: knife or bullet injury, multiple sclerosis
Central cord syndrome
Clinical manifestations?
Causes?
- segmental loss of pain and temperature
- weakness often greater in the arms then legs
- Acute flexion injury
Conus medullaris syndrome
Clinical manifestations?
Causes?
- Bladder and rectal dysfunction, saddle anesthesia
- Disc herniation, trauma, tumors
Cauda equina syndrome
Clinical manifestations?
Causes?
- Asymmetric multi radicular pain, leg weakness, and sensory loss; bladder dysfunction
- disc herniation, tumor, lumbar spine stenosis
Cohort
- pick exposed and non exposed groups and compare their incidence of disease
retrospective cohort
-examines two groups with different exposures and compares their outcomes retrospectively usually by chart review
Atropine and diphenoxylate ingestion in toddler
toxidrome?
tx?
-anticholinergic effects; tx: physostigmine
Electrolyte abnormalities in oleander????
-hyper K, b/c has dig-effects
Propranolol antidote????
glucagon
Ingestions visible on plain films???
(“CHIPS” mnemonic) Chloral hydrate Heavy Metals Iron Paraldehyde Sustained release
criteria for rheumatic fever
JONES PEACE Major criteria: •J oints: migratory •O (heart shaped) Carditis: new onset murmur •N odules, subcutaneous: extensor surfaces •E rythema marginatum •S ydenham's chorea. Minor criteria: •P R interval, prolonged •E SR elevated •A rthralgias •C RP elevated •E levated temperature (fever) *Need 2 major or 1 major and 2 minor criteria, plus evidence of recent GAS infection (throat cx, rapid antigen test, or rising strep antibody titer).
CPR C:V ratios
- single-rescuer CPR, 30:2
- two or greater rescuer CPR, 15:2
Acute radiation syndrome predictor?
- most commonly used method of estimating dose exposure and prognosis is the Andrews lymphocyte depletion curves
- examines the level of lymphocyte decline over 48 hours
- lymphocyte count at 48 hours that best predicts the patient’s course.
VX
- inhibits acetylcholinesterase at the nicotinic and muscarinic receptors, leading to effects at the end organs
- muscarinic toxidrome includes miosis, bronchoconstriction, vomiting and diarrhea, bronchorrhea, urination, and salivation
- Effects at the nicotinic receptors include weakness, fasciculations, and flaccid paralysis
- Initial symptom relief is improved by the use of atropine and aging is prevented by prompt use of pralidoxime chloride
clonidine overdose symptoms?
usual presentation of clonidine overdose consists of an alteration in mental status, respiratory depression, bradycardia, hypotension, and miosis
type 1 error?
alpha=rejecting a true null hypothesis
-stating there is a difference when none exists
p = probability of making a type 1 error
type 2 error?
beta = not rejecting a false null hypothesis
-stating there is no difference when one exists
beta = the probability of making a type 2 error
Power?
1-Beta
-probability of rejecting a null hypothesis when it IS false
= the probability of not making a type 2 error
not shockable rhythms???
asystole
pulseless electrical activity
proper site for paracentesis???
3 cm above and 3 cm medial to the anterior superior iliac spine
Hangman’s fracture
- C2 (axis) fracture
- fracture of the pars interarticularis and is usually caused by hyperextension of C2
Jefferson fracture
- Burst fracture of C1 (atlas)
- due to axial-loading compression force
lunate dislocation sx?
- tenderness over the volar aspect of the wrist and median nerve dysfunction
- XR shows both a “spilled teacup” and “piece of pie sign” on imaging
- If the third metacarpal head is in line with the second and fourth metacarpal heads, Murphy’s sign is considered positive and indicates a lunate dislocation (When viewing the dorsum of the hand in a fist, the MCP joint formed by the third metacarpal head normally extends more distally than the second or fourth metacarpal heads)
Angel’s trumpet???
- (Brugmansia and Datura species) is abused for its hallucinogenic properties (induces profound delirium) and has tropane alkaloids (atropine, hyoscyamine), resulting in associated anticholinergic effects
- delirium, auditory and visual hallucination, tachycardia, hypertension, dry skin, dilated pupils, flushing, intense thirst, abdominal cramps, emesis, urinary retention, and muscle weakness
Foxglove
is Digitalis purpurea and can cause arrhythmias, bradycardia, emesis, and sedation
?,?, and ? inhibit hepatic microsomal enzymes and will increase carbamazepine levels, leading to toxicity.
Erythromycin, clarithromycin, and cimetidine
Ankle-brachial indices and API (arterial pressure indices)
- calculated by dividing the systolic blood pressure of the affected limb by the brachial artery systolic pressure or unaffected limb systolic pressure
- considered abnormal if less than 0.9 and further evaluation is indicated
causative agent for Lyme disease?
- Borrelia burgdorferi
- typically presents with the classic erythema chronicum migrans rash and can be associated with arthralgias, fever, aseptic meningitis, and cranial nerve VII palsy
t-test and analysis of variance or ANOVA are parametric tests or nonparametric tests ?
parametric tests
Wilcoxon/Kruskal Wallis or rank sum tests are parametric or nonparametric tests?
nonparametric tests
χ-squared test is used for?
used to compare proportion of subjects in 2 groups
- 2x2 table
pediatric hernias
- type?
- cause?
- indirect inguinal hernia
- occurs as a result of a persistent anatomic patency of the canal of Nuck in females
- processus vaginalis in males
BEST predictor of morbidity and mortality in submersion injuries is?
-duration of submersion
treatment of choice for Addisonian crisis
- hydrocortisone sodium succinate (dose, 3mg/kg, or 25 mg for infants, 50 mg for younger children, and 100 mg for older children)
- methylprednisolone does not have minerolcorticoid activity
if heart rate is less than 60 beats/min in a fresh neonate???
- start chest compressions at a rate of 120/min with a 3:1 compression to ventilation ratio
- Consider using epinephrine if the heart rate remains below 60 beats/min despite adequate oxygenation
Nifedipine in the mountains
-Inhibits pulmonary arteriolar vasoconstriction
-High-altitude pulmonary edema treatment
-No role for acute mountain sickness and high-altitude
cerebral edema
HUS
- diagnostic triad?
- cause?
- thrombocytopenia
- microangiopathic hemolytic anemia
- renal injury
- Ninety percent of cases of HUS are associated with Shiga toxin–producing enterohemorrhagic strains of Escherichia coli or Shigella
- Seventy percent of typical HUS cases are due to E coli, mainly E coli 0157:H7
PTH has 3 effects on calcium: ???
(1) it increases 1,25-dihydroxy vitamin D level, which increases GI absorption of calcium
(2) increases mobilization of calcium from bone
(3) decreases renal excretion of calcium.
foxglove, oleander, & lily-of-the-valley
What it do?
Tx?
Cardiac glycosides
GI: Nausea, vomiting
CNS: Sedation
Cardiac: PR prolongation, QT shortening, bradycardia, ventricular arrhythmias
-Treatment similar to digitalis poisoning. Reversible inhibition of the Na+/K+ ATPase pump –> hyperkalemia –> cardiac changes of bradycardia with heart block, atrial tachycardia, VT, & VF.
Treatment = antidote—digoxin antibody Fab fragments.
(jimson weed), Atropa belladonna (nightshade)
Toxin = Hyoscyamine, scopolamine (anticholinergics)
CNS: Agitation, hallucinations,
Cardiac: Tachycardia, hypertension
What do you see in association with calcaneal fractures?
10% of calcaneal fractures are associated with lumbar spine fractures
first line agent for treatment of ABRS
IDSA recommend that high-dose amoxicillin-clavulanate should be considered the first line agent for treatment of ABRS.
–Amoxicillin alone is an alternative, but should be administered in higher doses (90 mg/kg/day) to overcome the high endemic rate of penicillin resistant pneumococcal strains
Normal ABI???
ABI should be 0.9 or greater
Urine smells like…? What is Dz?
- maple syrup or burnt sugar
- sweaty feet
- mousy or musty odor
- fishy odor
Maple syrup urine disease: maple syrup or burnt sugar
Isovaleric acidemia: sweaty feet
Phenylketonuria: mousy or musty odor
Trimethylaminuria: fishy odor
Chi-Square / Fisher Exact
test
- nonparametric
- For categorical data
- ie. Comparison of cellphone use in a class room (yes and no) between male and female students.
Evaluation of suspected urethral injuries???
- retrograde urethrography (RUG) is the gold standard in males to assess for urethral injuries; inadequate in females
- Urethroscopy is indicated in the evaluation of female patients; it should be combined with cystoscopy and vaginoscopy in this case (unstable pelvic fxs)
The recommended first-line antiarrhythmic for ventricular fibrillation and wide complex tachycardia is??
amiodarone
-after multiple rounds of epi and 2 shocks
measures to help acutely lower an increased ICP include the following: (4)????
- hyperventilation, usually to a Pco2 of 30 to 35 mm Hg
- elevation of the head of the bed to 15° to 30° ( elevating the head to greater than 40° may impair perfusion pressure)
- Mannitol 0.25 to 1 g/kg intravenous bolus of the 20% solution
- 3% Hypertonic saline 2 to 6 mL/kg intravenous bolus
Drugs that can be administered via the ET route?
LEAN = lidocaine, epinephrine, atropine, and naloxone
Indications for defib?
Defib indicated for
- VF
- Pulseless VT, regardless of the waveform
- Unstable, polymorphic (irregular) VT with or without pulses
Defib not indicated for
- asystole
- PEA
- SVT
- stable VT with pulses
Pt with hyperammonemia…
what is the appropriate nitrogen scavenger therapy??
-ie, sodium phenylacetate and sodium benzoate
Pt with hyperammonemia…
what is the appropriate nitrogen scavenger therapy??
-ie, sodium phenylacetate and sodium benzoate
ECG in in Brugada syndrome will show…
-elevated ST segments with coved or sloping morphologies, described as “saddle back”
LET has a final concentration of lidocaine __?__%
4
You have a patient with hyponatremia, leukopenia, elevated liver function test results, and thrombocytopenia. You assume that they have what disease?
Rocky Mountain spotted fever or ehrlichiosis
Treatment for a trench mouth is?
Penicillin!
What abx for neonate with omphalitis?
Vancomycin, cefotaxime, and metronidazole
You have a patient that is cyanotic with a pulse oximetry reading of 90%. Cyanosis does not improve with oxygen. What is the diagnosis and treatment?
Diagnosis is methemoglobinemia. Treatment is methylene blue one to 2 mg per kilogram. Of note, gastroenteritis is enough to cause this presentation. methemoglobin formation results from conversion of iron from the ferrous to the ferric state in response to the oxidant stress such as dehydration or acidosis. Implicated organisms are E. coli and Campylobacter.
-Young infants lack the reductase enzyme that is required to reduce the ferric state and restore normal hemoglobin
Treatment of dysfunctional uterine bleeding and is?
Combined oral contraceptive. Estrogen provides hemostasis. Progesterone stabilizes the endometrial lining.
Laboratory findings in Kawasaki’s disease are?
Anemia for age Elevated ALT Albumin 10 WBC/hpf) Platelets > 450K after 7 days WBC > 15,000
Treatment of carbon monoxide poisoning?
Indications for hyperbaric oxygen therapy are?
- Carbon monoxide poisoning is treated by providing 100% oxygen via non-rebreather mask
- Indications for hyperbaric oxygen therapy are carbon monoxide concentrations greater than 25%, carbon monoxide concentrations greater than 15% in pregnant patients, loss of consciousness, severe metabolic acidosis (pH less than 7.1), evidence of endorgan ischemia such as EKG changes and altered mental status, GCS less than 15, and persistent neurologic signs or symptoms
What is the major difference between GBS and transverse myelitis?
In contrast to transverse myelitis, the paralysis typically is ascending and does not involve any sensory loss in spite of paresthesias.
Loop diuretic
- furosemide
- induces calciuresis
Thiazides and calcium?
Increase renal tubular absorption of calcium and are contraindicated in patients with hypercalcemia
Norepinephrine
-For warm shock and neuro shock
Acts on alpha-1 and beta-1 receptors,
Producing potent vasoconstriction ; incr SVR
Less pronounced increase in CO
