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