Acute Care Flashcards
How would you prepare for intubation
SOAPME Suction Oxygen Airway Pharmacology Monitoring equipment
What are contraindications for succylcholine?
HyperK Neuromuscular disorder Renal failure Burns Crush injury History of malignant hyperthermia or pseudocholinesterase deficiency Glaucoma Penetrating globe injury
What ratio of blood products (RBC/FFP/cryo) do you need in a massive transfusion protocol?
1:1:1
Causes of secondary brain injury
Hypotension Hyperthermia Seizures Raised ICP Hypo/hypercarbia Hypo/hyperglycemia Hypoxemia
How would you manage an intracranial bleed?
Intubate if GCS <8 Hyperventilation via ETT with goal paCO2 30-35 mmHg Give mannitol, 3 cc/kg 3% Raise head of bed 30 degrees RSI if intubating Maintain normothermia, normal BP< euglycemia, treat seizures Call Neurosurgery Maintain CPP >40
If you are <8 years, are more likely to injure upper or lower C-spine?
Upper (C1-C3)
If you have parasthesiaes and tingling and C-spine x-rays and CT are normal, what is the diagnosis?
SCIWORA-spinal cord injury without radiographic evidence of spinal cord injury
Can see abnormalities on MRI
What are the NEXUS criteria for clearing the C-spine?
No midline cervical spinal tenderness No focal neurologic deficit No distracting injury Normal alertness No intoxication No pain with flexion, extension, and rotation of head 45 degrees to both sides
When should you do a CT head for minor head injury? (CATCH rules)
Any ONE of the following:
High risk (need for intervention)
- GCS <15 at two hours post injury
- Suspected open/depressed skull fracture
- Worsening headache
- Irritability on examination
Medium risk (brain injury on CT scan)
- Signs of basilar skull fracture
- Large boggy, hematoma of scalp
- Dangerous mechanism (fall from >3 ft, fall from bicycle no helmet, MVA)
What are the indications for a CT C-spine?
Inadequate C-spine radiographs (3 views)
Suspcious xray findings
High index of suspicion despite normal CXR
How do you differentiated between pseudosubluxation of C2 vs subluxation?
Draw line of swischuk from posterior arch of C1-C3 and if intersects same point on C2 normal (spinolamellar line should straight despite apparent malalignment of vertebral bodies!)
http://www.wheelessonline.com/ortho/pseudosubluxation_of_the_c_spine
When can you see pulmonary contusion on CXR?
At presentation, but can be delayed to 6-8 hours
How long does it take to recover from pulmonary contusion?
Usually 3 days
If there are greater than ___ rib fractures, suspect that there is other thoracic injury
4
What is the most common liver injury?
Hematoma
Laceration
Right hepatic lobe most commonly affected
In a trauma, after how many boluses should you order blood
2
10 cc/kg pRBC
Indications for surgery in trauma
Hemodynamic instability
Major vascular injury
Major penetrating trauma
Injury to bowel, bladder or mesentery
What injuries are associated with a lap belt injury?
Chance fracture-transverse L1/L2/L3 vertebral # (Think if no urine output and not moving legs)
Compression
- Tear/avulsion of mesentery
- Rupture of small bowel/colon
- Thrombosis of iliac artery or aorta
What heals faster metaphyseal/growth plate fractures or diaphyseal fractures?
Metaphyseal/growth plate # heal in half the time
Due to increased vascularity
What fractures are unique to children?
Greenstick Buckle Bowing Avulsion Salter Harris (IV needs surgical intervention; III sometimes)
How do you manage clavicular fractures?
For Girl under 12 years old
Boy under 14 years old OR older with <100% displacement and <2 cm shortening:
Analgesia
No reduction
Immobilize in broad arm sling
Remove sling at 3 weeks and do ROM exercises
> 12 years old for girls and >14 years old for boys and >100% displacement and >2 cm shortening/medial 1/3 clavicle/dislocation of AC joint:
Call Ortho
How do you assess neurovascular status in upper limbs?
Pulse Capillary refill Motor and sensory: -Radial: lateral dorsal hand, thumbs up -Ulnar: lateral ventral hand, spreading fingers -Median: medial ventral hand, OK
What 4 things are you looking for on an elbow xray?
1) Posterior fat pad, wide anterior fat pad
2) Anterior humeral line-should go through middle third of capitellum
3) Radiocapitellar line
4) Figure of eight
5) CRITOE ossification centers
Capitellum
Radius
Internal condyle
Olecranon
External condyle
What is a monteggia fracture?
MUGER
Ulnar fracture
Radial head dislocation
What are complications associated with monteggia fracture?
Compartment syndrome
Median/radial nerve injury
Delayed reduction
What is a galleazi fracture
MUGER
Radial fracture
Ulnar head dislocation
How do you treat buckle fractures?
Immobilize in removable splint
Remove in 3-6 weeks
How do you diagnose SCFE on hip x-ray?
Frog leg view
Draw klein line (line along lateral femoral neck should intersect femoral head)
https://www.ebmedicine.net/media_library/aboutUs/Normal%20Klein%20line%20drawn%20along%20the%20lateral%20femoral%20neck%20intersecting%20the%20femoral%20head%20bilaterally%20Pediatric%20Emergency%20Medicine%20Practice.JPG
How does SCFE typical present?
Obese adolescent male
Chronic hip/thigh/knee pain
25% are bilaterally
How do you treat toxic alcohol ingestion (methanol/ethylene glycol/isopropanol)?
1) Fomepizole
- Blocks alcohol dehydrogenase and prevents formation of toxic metabolites
2) Adjuncts
- Folate-for methanol
- Pyridoxine for ethanol
3) Hemodialysis
- Methanol level of >50 mg/dL, acidosis
- Severe electrolyte disturbances
- Renal failure
Where do you find toxic alcohols?
Methanol-windshield washer fluid
Ethylene glycol-antifreeze
Isopropanol-pain remover, windshield de-icer, rubbing alcohol
What should you measure if you are concerned about an alcohol ingestion?
1) Osmolar gap
Calculated = 2xNa + glucose + urea
Measured – calculated = normally 0-5
2) Anion gap
Na-HCO3-Cl
Normal=8-12
What are the features of ethanol ingestion?
Hypoglycemia (if peak serum level ≥50 mg/dL (11 mmol/L) Lethargy Ataxia Slurred speech Hypothermia Bradycardia Hypotension Respiratory depression Sickly sweet breath
How do you manage ethanol ingestion?
Supportive
Observe x 6 hours
Check sugar
Which drugs can be toxic in small amounts for a 10 kg child?
Methyl salicylate (<1 tsp) Camphor (1 tsp) Chloroquine and quinine Tricyclic antidepressants (amitrityline) Calcium channel blockers (nifedipine, verapamil) Clonidine Opioids (methadone, hydrocodone) Oral hypoglycemics (glyburide)
What are the features of methanol ingestion?
Severe, refractory metabolic acidosis
Retinal damage
LATENT PERIOD
What are the features of Isopropyl alcohol ingestion?
Gastritis
CNS depression, Hyperglycemia
Hypotension
No AG
What are the features of ethylene glycol intoxication?
Severe metabolic acidosis Seizures Coma Renal damage via ca oxalate crystals HypoCa leading to arrythmia Puomonary/cerebral edema LATENT PERIOD
What causes an increased AG (MUDPILES)?
M ethanol U rea D KA P araldehyde I soniazid, Iron L actic acidosis E thylene glycol S alicylates
What is a significant iron ingestion?
> 60 mg/kg elemental iron
What are the 4 phases of iron ingestion?
Four acute phases of iron ingestion:
1) 30 min - 6 hr
GI
Vomiting, diarrhea, hypovolemic shock, abdominal pain and gastrointestinal hemorrhage
2) 6 - 24 hr
RELATIVE STABILITY
GI symptoms get better; lasts 6-12 hours
3) 12 - 24 hr
SHOCK
MODS, shock, hepatic and cardiac dysfunction, ARDS, profound metabolic acidosis.
DEATH
4) Hepatotoxicity: occurs within the first 48 hours; second most common cause of mortality
5) 2-6 weeks
GI strictures and obstruction
How do you treat iron ingestion?
NO CHARCOAL
Whole bowel irrigation
IV fluids for GI symptoms
If acidotic, need Na bicarbonate
Chelation with IV deferoxamine IF
1) Symptoms
OR
2) Serum iron level >350-500 mcg/dL
In what time frame activated charcoal most effective?
Most effective if given within 1 hour of ingestion
When should you give Ipecac or gastric lavage?
Never
For what medication overdoses should you use multidose activated charcoal?
Extended release medications Theophylline Carbamazepine Dapsone Phenobarbital Quinine
What investigations do you order in iron ingestion?
Iron level CBC chemistries, BUN, creatinine glucose LFTs ABG type and cross match as needed x-ray-may show pills
When should you do whole bowel irrigation for a toxic ingestion?
- Sustained release tablets
- Cocaine/heroin body stuffers
- When charcoal not effective: e.g, iron/lead/lithium/zinc
What do the following serum iron levels mean in a toxic ingestion?
<350 mcg/dL
350-500 mcg/dL
>500 mcg/dL
<350 mcg/dL: when drawn 2 to 6 hours after ingestion, usually predict a benign course
350 to 500: mild phase I symptoms
> 500: risk of shock
In a toxic ingestion, which medications can you see on x-ray? (CHIPES)
Choral hydrate Heavy metals Iodides Phenothiazines Enteric coated pills Sustained release medications
What are the symptoms of salicylate overdose?
Hyperpnea/tachypnea-salycylate acts at resp center in medulla
Diaphoresis
Tinnitus
Vomiting
Severe-altered LOC, seizures, hyperthermia
What are the goals in managing a salicylate overdose?
1) Supportive
- Aggressive fluid resuscitation
- avoid intubation if possible; difficult to achieve high minute ventilation necessary
- Supplemental glucose if obtunded despite normal peripheral glucose levels (because CNS glucose may be decreased)
- Replete potassium-hypoK can interfere with urine alkalinization
2) Gastric decontamination
- Activated charcoal
- Multiple dose activated charcoal
- Suspect bezoar if levels rise hours after ingestion
3) Elimination enhancement
i) Urine alkalinization
- Goal is to achieve urine pH >7.5
- NaBic bolus and infusion
ii) Hemodialysis may be needed
4) Laboratory monitoring
- Urine pH
- ABG, salicylate level
What investigations should you order in salicylate poisoning?
Salicylate level Blood gas-AG acidosis and resp alkalosis Electrolytes and glucose Creatinine-can be elevated Urinanalysis-follow urine PH to determine success of alklalinization
What is a toxic dose of acetaminophen?
> 150 mg/kg in children
>7.5-10g in teens/adults
When do you take an acetaminophen level and what other tests should you order at this time?
4 hours
LFTs
RFTs
Coags
How do you manage acetaminophen overdose?
1) Activated charcoal if <4 hours
2) N-acetylcysteine based on Rumack-Matthew nomogram-give if tylenol >150mg/L at 4 hours
What are the clinical features of anticholinergic toxidrome?
Main differentiating factor is that they are dry (incl urinary retention), but hot and red!
Mad as a hatter (altered mental status, hallucinations)
Fast as a hare (tachycardia, hypertension)
Hot as hell (hyperthermia)
Dry as a bone (dry mucous membranes)
Blind as a bat (mydriasis, blurred vision)
Full as a tick (urinary retention, decr GI motility)
Red as a beet (flushed skin)
What are some anticholinergic medications?
Antihistamines TCAs Phenothiazines Anti-parkinsonian medications Jimsonweed Antispasmodic agents Mydriatic agents Bronchodilator agents (ipratropium)
What are the clinical features of cholinergic toxidrome?
Wet!
DUMBELS
Diaphoresis Diarrhea Urination Miosis Bradycardia Bronchospasm Emesis Lacrimation Salivation Seizures
What are some drugs causing cholinergic toxidrome?
Insectiside
Physostigmine, neostigmine, pyridostigmine, edrophonium
Alzheimers meds
What are the clinical features of sympathomimetic toxidrome?
Similar to anticholinergic, but wet
Anxiety Delusions Paranoia Hyperreflexia Mydriasis Seizures Piloerection Diaphoresis
What are some drugs causing sypathomimetic toxidrome?
LSD PCP Amphetamienes Pseudoephedrine Theophylline Ecstasy Cocaine
What is special about PCP ingestion?
Horizontal, vertical, or rotatory nystagmus
RIGIDITY
Other features: AMS (eg, lethargy, irritability) Emotional lability Choreoathetosis Seizures Ataxia Blank staring
How to differentiate serotonin syndrome from neuroleptic malignant syndrome and anticholinergic syndrome?
NMS typically develops over longer period (days to weeks vs 24 hours)
Serotonin syndrome is characterized by neuromuscular hyperreactivity (tremor, hyperreflexia, myoclonus), while NMS involves sluggish neuromuscular responses (rigidity, bradyreflexia).
Anticholinergic usually has normal reflexes and tone
What are the clinical features of serotonin syndrome (triad)?
1) Altered mental status
2) Autonomic instability
- Shivering, sweating, hyperthermia, hypertension, tachycardia, Nx, Dx
3) Neuromuscular hyperactivity
- Muscle twitching
- Hyperreflexia
- Clonus
- Tremor
4) For citalopram-QTc prolongation + seizures
What medications can cause serotonin syndrome?
Ecstasy LSD SSRI’s MAOIs Linezolid Tramadol Meperidone Valproate Fentanyl Ondansetron Metoclopramide Sumatriptan Dextromethorphan Dietary and herbal products: St. John’s wort, ginseng
What are the clinical features of GHB?
Ingestion results in drowsiness, dizziness and disorientation in 15-30 min
Respiratory depression
Bradycardia
Hallmark is AGITATION WITH STIMULATION
Won’t show up on tox screen
How do you treat GHB ingestion?
Supportive-airway
Atropine for severe bradycardia
Monitor for 4-6 hours
What specific drugs can you ask for levels for in a suspected ingestion?
ASA Acetaminophen Ethanol Digoxin Iron Lithium Theophylline
What general investigations do you order in a suspected ingestion?
ECG Serum electrolytes Serum osmolality ABG AG and osmolar gap Urine tox Specific drug levels
What ECG abnormalities do you see in TCA overdose?
Prolongation of the QRS >100
Abnormal morphology of the QRS (eg, deep, slurred S wave in leads I and AVL)
Abnormal size and ratio of the R and S waves in lead AVR)
What are your management priorities in a TCA overdose?
1) ABCs
- Norepinephrine for hypotension
2) Activated charcoal if ingestion within 2 hours
3) Serial ECGs
4) NaBic
- Indidcations: QRS >100, arrythmias, hypotension
- Continue for at least 12-24 hours
- Goals of therapy:
i) Serum pH of 7.45-7.55
ii) Hemodynamic stability
iii) Narrowing of the QRS complex.
5) Benzos for seizures
What are the three types of toxicity in TCA overdose and what are the associated symptoms?
1) Cardiac
- Sinus tachycardia, QRS prolongation, ventricular arrythmias
2) CNS
- Lethargy, coma, myoclonic jerks, and seizures
3) Anticholinergic
- Delirium, mydriasis, dry mucous membranes, tachycardia, hyperthermia, mild hypertension, urinary retention, and slow GI motility
What are side effects of PGE1?
Apnea Bradycardia Hypotension Seizures Fever
How do you perform a hyperoxia test?
Take PaO2 in room air
Administer 100% O2
Repeat PaO2->100=normal
When do neonates with HSV typically present?
4-7 days of life
HSV encephalitis-7-21 days
Explain the pathophysiology of methemoglobinemia
Normally heme is Fe2+ (ferrous)
When oxidized to the ferric state (Fe3+) (METHEMOGLOBIN), the heme becomes unable to bind O2
The remaining ferrous heme develops increased O2 binding affinity à decreased tissue delivery
Normal values 0-3%
List 6 causes of methemoglobinemia
Infants
- Endogenous production due to diarrhea, vomiting, acidosis
- Bottle fed infant exposed to nitrates in well water
- Congenital methemoglobinemia
Older kids:
-Antibiotics: Dapsone, Sulfamethoxazole
-Topical Anesthetics: Benzocaine, Lidocaine, Prilocaine
-Nitrates/Nitrites: Contaminated water, nitroglycerin, iNO, nitrous oxide
-Antimalarials: Chloroquine, Primaquine
-Antineoplastics: Cyclophosphamide
Aniline Dyes
What are the clinical features of galactosemia (cannot convert galactose to glucose)?
Vomiting Diarrhea FTT Jaundice (conjugated hyperbili) Cataracts
How do you treat galactosemia?
Treat hypoglycemia dn shock
Lactose free formula (e.g. nutamigen)
How do urea cycle defects present?
Poor feeding
Hypotonia,
Seizures
Hepatomegaly without liver failure
How do you treat UCD?
Glucose D10NS 2x maintenance (stimulates insulin and decrases protein catabolism)
How remove nasal foreign body?
Parents kiss-parent makes firm seal over kids mouth and gives short puff of air while occluding the unaffected side
Insert foley into nares, inflate and pull forward
How do you treat an embedded earing?
Inject lidocaine Make small incision Remove stud with stud with forceps/probe Irrigate well Discharge with antibiotics No earring x 6-8 weeks
How do you treat a subungal hematoma?
Nail trephination
Clean nail with betadine
X-ray if suspect fracture
Digital block/local anaesthetic
Use electrocautery wire/18G needle to create hole in nail over hematoma
After what time period is nail trephination for subungal hematoma unlikely to be successful?
48 hours
What is paronychia?
Superficial infection of the skin bordering base of the nail fold
How do you treat paronychia?
If no pus-warm soaks, elevation, antibiotics
If pus
-Need to drain; can use scalpel along side of nail
-May need digital block
What is the maximum dose of lidocaine you can use with and without epinephrine?
With epinephrine 7 mg/kg
Without epinephrine 5 mg/kg
How much do you irrigate a wound before you suture it?
100 ml per cm
Use 18G angiocath
If you are putting in non-absorbable sutures, how long do you keep them in for?
5-7 days
What are contraindications to using tissue glue?
Infected wound Deep wound (e.g. cat bite) Edges do not approximate well Near to eye Mucous membranes
How do you manage laceration to hand/foot with glass?
X-ray to rule out retained glass Check neurovascular status Check for tendon injury Assess tetanus tatus Refer to plastics if tendon/neurovascular injury
How do you manage a dog bite?
1) Tetanus-give booster if hasn’t had vaccine in 10 years
2) Notify public health to find stray dog and arrange rabies prophylaxis
3) Clean well; can be sutured
4) Antibiotic prophylaxis with clavulin
Which animals are at highest risk of carrying rabies?
Stray dogs Cats Skunks Raccoons Foxes Bats-must have direct contact Cattle
What is rabies prophylaxis?
Rabies Ig now
Rabies vaccine day 0, 3, 7, 14
List 3 signs of penetrating globe injury
Tear drop pupil
Hyphema
360 degree subconjunctival hemorrhage
How do you manage penetrating globe injury?
Shield eye (no patching, no fluorescein) Urgent referral to Optho
What are signs of corneal abrasion?
Photophobia
Foreign body sensation
Tearing
How do you diagnose corneal abrasion?
Instill fluorescein drops and examine with ophthalmoscope using blue light setting
Abrasion will appear as a green spot on the cornea
Can use tetracaine drops to aid in examination
How do you treat corneal abrasion?
Evert eyelid and remove FB with cotton swab
Pressure patch
Name 5 things you will assess about a burn to determine management
Total body surface area Depth of burn, +/- blistering Involvement of hands, feet, genitalia Circumferential burn Pattern of burn suggestive of abuse
What is parkland formula (for >10% TBSA) ?
4cc/kg/%TBSA burn
1/2 in first 8 hours; remaining in 16 hours
How do you diagnose methemoglobinemia?
- Hypoxia that doesn’t improve with high fiO2
- Cyanosis in the presence of a normal PaO2 – “Saturation Gap”
- Measure metHb %
Why is pulse oximetry inaccurate in methemoglobinemia?
Pulse oximetry only measures normal oxyhemoglobin and total hemoglobin
List 5 management steps for methemoglobinemia
- Stop the offending agent
- 100% O2
- If <20% metHgb → observe
- If >20% metHgb → methylene blue
- If in shock → Transfusion of PRBCs or Exchange Transfusion, Hyperbaric O2
Name one contraindication to methylene blue
G6PD deficiency (can use ascorbic acid instead)
Name 4 indications for intubation in inhalation injury
- Stridor
- Increased WOB
- Resp distress
- Hypoventilation
- Deep burns to the face/neck
- Blistering or edema of the oropharynx (develops in first 24h)
Name 5 symptoms of CO poisoning
Headache, N/V Malaise Altered LOC, Seziures, Coma SOB Arrhythmias/CHF Bright "cherry red" lips
How do you treat CO poisoning?
Give 100% fiO2
Consider need for hyperbaric oxygen (HBO) therapy
What two types of poisoning should you suspect in inhalation injury?
CO
Cyanide
How do children get cyanide poisoning?
Hydrogen cyanide is a byproduct of burning certain compounds (e.g, plastic, nylon, wool, cotton)
What is the pathophysiology of cyanide poisoning?
Inhibits aerobic metabolism and can rapidly result in death
Name 5 clinical features of cyanide poisoning
Coma Central apnea Cardiac dysfunction Severe lactic acidosis High mixed venous O2
How do you treat cyanide poisoning?
High flow O2
Decontamination
Antidotes (e.g. sodium thiosulfate + hydroxocobalamin)
List 3 causes of lactic acidosis in a burn patient
CO poisoning
Cyanide poisoning
Hypoxemia
Tissue necrosis
Describe the mechanism by which ORS works
ORT works by taking advantage of glucose/Na co-transporter across intestinal membrane (remains intact in infectious diarrhea)
Glucose enhances Na absorption → Na causes water absorption
Optimal glucose/Na ratio for absorption is 1:1
What is the ideal composition of ORS?
Low osmolarity-200-250 mOsm/L
Na 45-50 mmol/L
What is the % dehydration?
Markedly decreased or absent urine output Greatly increased thirst Very dry mucous membrane Greatly elevated heart rate Decreased skin turgor Very sunken eyes Very sunken anterior fontanelles Lethargy, Coma Cold extremities, Hypotension
> 10%
What is the % dehydration?
Slightly decreased urine output
Slightly increased thirst
Slightly dry mucous membrane
Slightly elevated heart rate
<5%
What is the % dehydration?
Decreased urine output Moderately increased thirst Dry mucous membrane Elevated heart rate Decreased skin turgor Sunken eyes Sunken anterior fontanelle
5-10%
How much fluid should you give a patient with mild dehydration (<5%)?
1) Rehydrate with ORS 50 ml/kg over 4 hours
2) Replace losses with ORS
3) Age appropriate diet after rehydration
How much fluid should you give a patient with mild dehydration (5-10%)?
1) Rehydrate with ORS 100 ml/kg over 4 hours
2) Replace ongoing losses with ORS
3) Age appropriate diet after rehydration
How much fluid should you give a patient with mild dehydration (>10%)?
1) IV resuscitation with NS/RL 20-40 ml/kg over 1 hour
2) Reassess and repeat if needed
3) ORT when stable
4) Replace ongoing losses with ORS
5) Age appriorpiate diet after rehydration
Why should alternatives to ORT be discouraged (juice, carbonated drinks)?
Increased carbs, decreased electrolytes, increased osmolarity; can cause osmotic diarrhea
Name 3 contraindications to ORT
Prolonged vomiting despite small freq amounts Severe dehydration Impaired LOC Paralytic ileus Monosaccharide malabsorption
Should breastfeeding be continued during rehydration?
YES
Early refeeding is beneficial
↑ absorption nutrients, enhances lyte replacement, ↓ diarrhea duration
In what age group is single dose ondansetron most effective for mild/moderate dehydration? (CPS)
6 months to 12 years
What should be the endpoints guiding resuscitation in shock?
HR
U/O (to 1 mL/kg/hr)
Cap refill (to <2 sec)
Mental status
What happens if IV phenytoin extravasates?
Purple glove (edema, discoloration and pain) b/c of pH
Name 3 side effects of fosphenytoin
Cardiac arrhythmias
Bradycardia
Hypotension
Which AED is less effective if seizure is refractory to benzodiazepines?
Phenobarbitol (similar mechanism of action as benzodiazepines)
Name 2 situations in which phenobarbitol should be used as a first line AED
Neonates
Patients on maintenance phenytoin
List 3 most common triggers for asthma exacerbations
Viral URTIs
Exposure to allergens
Poor control
Name 5 side effects of ventolin
Tachycardia
Low K+
Hyperglycemia
Lactic acidosis
During what time frame should atrovent be used?
Only evidence for use in 1st hour with reduced hospital admission and better lung function
When should MgSO4 be given in acute asthma?
Moderate and severe acute asthma, if no response during first 1-2 hours of treatment
Name 2 side effects of MgSO4
Hypotension
Bradycardia
Name 2 serious complications in asthmatics who are intubated and ventilated
Pneumonthorax
Impaired venous return and cardiovascular collapse
List one risk associated with IV salbutamol
Arrythmia
How many puffs of salbutamol should be given via MDI based on weight?
<20 kg = 5 puffs
>20 kg =10 puffs
Describe the clinical features of Reyes syndrome
Rapidly progressive encephalopathy
Hepatic dysfunction
Often begins several days after apparent recovery from a viral illness, especially varicella or influenza A or B
Associated with ASA use
Name 3 laboratory abnormalities in Reyes syndrome
Elevated LFTs
Increased PTT
Hyperammonemia, Hypoglycemia
Metabolic acidosis
Describe the clinical features of hemorrhagic shock and encephalitis syndrome?
Fever Shock Diarrhea Seizures Hemorrhage Evidence of DIC Microbiologic cultures negative
List 5 risk factors for drowning
Male Exposure to water in a child’s environment Poor supervision Alcohol/drug use Limited swimming ability Medical conditons (Epilepsy, Long QT syndrome, toxin, syncope)
What are the 3 categories of injury in drowning?
Anoxic Ischemic Injury
Pulmonary Injury
Hypothermia
What is the body’s initial response to drowning?
Laryngospasm
What is the most common cause of mortality in drowning?
Anoxic brain injury
List 5 end organ effects of submersion injury
Pulmonary
- Fluid aspiration
- ARDS
- Non-cardiogenic pulmonary edema
Neurologic
- Cerebral edema
- Raised ICP
Cardiovascular
- Arrhythmias secondary to hypothermia and hypoxemia
- Myocardial ischemia
Acid-base and electrolytes
- Respiratory and/or metabolic acidosis
- Lytes usually normal (except Dead Sea-hyperNa, hyperMg, hyperCa)
Renal
-ATN
Coagulation
-DIC, hemolysis
List 6 evidence-based interventions for preventing drowning
MOST EVIDENCE:
Four sided fencing around pools with self-locking, self-closing gate
Others: Personal floatation devices (infants >9 kg, able to sit unsupported) Pool alarms/covers Swimming instruction (toddlers alays within arms length of adult) Supervision/lifeguards who Resuscitation Personal flotation devices Parent CPR instruction
List 5 poor prognostic signs in drowning
Submersion > 10 min (most critical factor)***
Time to effective basic life support >10 min
CPR > 25 min
Age >14 years
GCS <5 (i.e. comatose)
Persistent apnea and requirement of CPR in ER
Art blood pH <7.1 on presentation
Poor neurologic exam at 72 hours
List 5 good prognostic signs in drowning
Immediate bystander CPR Submersion <5 mins Pupils equal and reactive at scene, GCS >15 Normal sinus rhythm at scene ROSC <10 mins
Describe the pathophysiology of drowning
- Breath holding
- Larygnospasm
- Hypoxia, hypercapnia, acidosis
- Airway reflexes abate and aspiration occurs
- Surfactant dysfunction, atelectasis
- Bradycardia, MODS
List the management steps in drowning
- Airway/Breathing
- If breathing-high flow O2
- If not spontaneously breathing, intubate
- Use circoid pressure
- Decompress stomach after airway secured
- Avoid abdominal thrusts
- C spine if trauma/alcohol/diving - Circulation
- CPR with backboard
- Shock x 3 if shockable rhythm
- Then wait until T>30C to see if arrythmia persists
- Drugs rarely effective until T>30
- Avoid hypotonic or glucose containing solutions
- Fluid and inotropic support as needed - Hypothermia
- Passive rewarming if T34-36
- Active external rewarming if T30-34
- Active internal rewarming if T<30
What is the definition of hypothermia?
<35C
Name 3 complications of hypothermia
Hypocalcemia Hypoglycemia Hypokalemia Metabolic acidosis Arrhythmia Pancreatitis!
Name 3 clinical features of hypothemia
31-32C
28-31C
<28C
31-32C Tachycardia Hypertension Loss of shivering Normal ECG
28-31C Bradycardia Hypotension Flipped T waves Osborn waves Atrial fibrillation Sluggish, dilated pupils
<28C Absent pulse VF Coma Fixed dilated pupils
Below what temperature are shocks and drugs ineffective?
T<30C
List 10 methods of rewarming
Passive rewarming:
Remove wet clothing
Dry
Active external warming: Electric blanket Overhead warmer Hot water bottles Heating pads
Active internal warming: Warmed IVF without K at 43C Warmed humidified O2 at 42-46C Peritoneal lavages ECMO Esophageal tubing
When should you think about C-spine precautions in a drowning patient?
- Diving
- Alcohol or other substances
- Trauma
When should resuscitation be discontinued in drowning?
Rewarm until temp is 32-34
If no effective rhythm by 25-30 mins, then stop CPR
What condition should you think about infant who is lethargic and has a seizure after swimming lesson?
Water intoxication (hypoNa(
What equipment do you need for intubation?
Call help (RT, nurses) Monitors O2 Suction Laryngoscope Appropriate size blade ETT (0.5 size smaller and larger) CO2 detector Intubation medications
Formula for ETT depth of insertion
3 x ETT diameter
What blades sizes are appropriate for
a) Newborn
b) Infant/small child
c) Child
d) Adolescent/adult
a) Newborn-0
b) Infant/small child-1
c) Child-2
d) Adolescent/adult-2
List 4 ways you can confirm correct placement of ETT initially
- Calormetric CO2 detector
- Equal breath sounds, mist in ETT
- ETT visualized passing through cords at glottic marker
- Good waveform on continuous end-tidal capnography
- Symmetric chest rise
Name 4 indications for intubation
- Unable to maintain airway patency
- Unable to protect against aspiration
a. GCS <8
b. Facial trauma
c. Airway edema/constriction
d. Tumour/mass blocking airway - Failing to maintain adequate oxygenation
a. WOB - Failing to maintain ventilation (hypercarbia)
a. Apnea, loss of respiratory drive - Sedation/paralysis required for procedure
List 3 complications of high PEEP
- Reduced preload (decreases cardiac output)
- Elevated plateau airway pressure (increases risk of barotrauma and pneumothorax)
- Impaired cerebral venous outflow (increases intracranial pressure)
Patient has flexion posturing, moans to painful stimuli and will not open her eyes to painful stimuli. What is GCS?
E1V2M3=6
List 5 characteristics of good quality CPR
- Optimal compression depth of at least 1/3 of the AP diameter of the chest
- Rate at least 100 compressions/min
- Allow for full chest recoil
- Minimize interruptions
- Avoid excessive ventilation
- Firm surface
Recommended ratio of compressions:breaths in single rescuer CPR
30:2
Recommended ratio of compressions:breaths in 2 rescuer CPR
15:2
Recommended ratio of compressions:breaths in ventilated patients?
Asynchronous
Chest compressions-100/min
Breaths 8-10/min
What 4 things should you think about in a deterioriating intubated patient?
Displacement of the tube
Obstruction of the tube
Pneumothorax
Equipment failure
What is the recommended method and dose of initial defibrillation?
Manual defibrillation
2J/kg, then 4J/kg
Definition of hypotension
0-28 days: <60 mm Hg
1-12months: <70 mm Hg
1-10 years: <70 mm Hg + (2 × age in years)
≥10 years of age: <90 mm Hg
What should you do for a choking infant with severe obstruction (cannot cough or make a sound)?
5 back blows, 5 chest compressions until object expelled or patient unconscious
What should you do for a choking child with severe obstruction (cannot cough or make a sound)?
Subdiaphragmatic abdominal thrusts (Heimlich maneuver) until the object is expelled or the victim becomes unresponsive
What should be done for a choking patient who is unresponsive?
Chest compressions x 30
Check for object in mouth
Give 2 breaths
Repeat
Treatment for torsades?
MgSO4
Name 2 indications for atropine in bradycardic arrest
Primary AV block
Increased vagal tone
Resuscitation dose of epinephrine
IV dose
Epinephrine 0.01 mg/kg (0.1mL) 1:10,000
ETT dose
0.1 mg/kg 1:1000
List 2 contraindications of adenosine in tachycardia
Wide complex tachycardia
WPW
What is the next step in patients with unstable tachycardia who fail adenosine and/or synchronized cardioversion?
Amiodarone
Target sats post resuscitation
94-99%
List 5 components of post resuscitation care
Maintain SO2 94-99%
Consider inotropic support/fluids
Treat seizures, agitation, hypoglycemia
Consider therapeutic hypothermia
Name 4 criteria required for neurologic determination of death
- Established etiology capable of causing neurological death in the absence of reversible conditions capable of mimicking neurological death
- Deep unresponsive coma with bilateral absence of motor responses, excluding spinal reflexes
- Absent brain stem reflexes as defined by absent gag and cough reflexes and the bilateral absence of
- corneal responses
- pupillary responses to light, with pupils at mid-size or greater
- vestibulo-ocular responses
4, Absent respiratory effort based on the apnea test
- Absent confounding factors
Guidelines for timing of physical exam for NDD:
Newborns
Infants (30 days- 1 year)
Children (>1 year)
Newborns
-Must have 2 full exams including complete
cranial nerve exam and apnea tests with ≥
24h interval between exams
-Must be ≥ 48h after birth
Infants (30 days- 1 year)
- Full, separate exams must be performed, but
no fixed interval
Children (>1 year)
-Still need two physicians, but can perform exam, including apnea
testing, concurrently
• If examined separately, apnea test must be repeated
In the setting of hypoxic-encepholapathic injury, when should NDD exam take place?
> 24H post injury
What are the components of the physical exam in NDD?
- Gag reflex
- Cough reflex
- Absence of motor responses
- Bilateral corneal reflex
- Bilateral pupillary responses to light and pupil size
- Bilateral vestibulo-ocular responses
- Apnea test
What is a positive apnea test?
Requires disconnection from mechanical ventilation followed by
• No respiratory effort
• CO2 increase by 20 mm Hg AND above 60 mm Hg AND pH ≤ 7.28
In what situations do you do ancillary testing for NDD?
- When apnea test impossible (e.g. ARDS, hypoxia)
- Do cerebral blood flow by angiography or radionuclide scan
- NO EEG
Name 3 contraindications to organ donation
Anancephaly Severe untreated systemic sepsis Active Hepatitis B/C/CMV/HIV Active extra-cranial malignancy Active Disseminated Tb Prion disease (CJD) Prion-related disease SSPE Disseminated TB Rabies Active West Nile Recipient of human growth hormone
Is NDD required for organ donation?
No, but on exam assume YES
Can also have donation after circulatory determination of death
List 5 reversible causes of coma
Metabolic disorders Meds, toxins Hypothermia Hypoxia Hypotension/shock, Hypoglycemia/hyperglycemia, Seizure Electrolyte abnormalities Sepsis/meningitis/encephalitis Bleed or brainstem lesions
Name 5 criteria for organ donation
●Neurologic death
●Treatment of any serious infection
●Free of malignancy with the exception of low-grade skin or brain tumors
●Free of systemic disease (eg, systemic lupus or end-stage renal disease) ●Hemodynamically stable (even with inotropic and pressor use)
What infusion should not be used for long term sedation?
Propofol
Propofol infusion syndrome-metabolic acidosis, rhabdo, death
List the SIRS criteria
2/4 of (≥1* required):
- Temp >38.5, or <36
- WBCs ↑ or ↓ or left shift >10%
- Tachycardia or bradycardia
- Tachypnea
pRBC transfusion threshold for sepsis?
Hb 100
What is the definition of ARDS?
PaO2/FiO2 <200
List 2 effects of dopamine
- ↑ Cardiac contractility
2. Significant peripheral vasoconstriction at >10 µg/kg/min
Name one side effect of dopamine at higher doses?
Increased risk of arrythmias
List 3 effects of epinephrine
- ↑ HR
- ↑ cardiac contractility
- Potent vasoconstrictor
Name 3 side effects of epinephrine at high doses
May ↓ renal perfusion at high doses
↑ Myocardial O2 consumption
Risk arrhythmia at high doses
Name 2 effects of dobutamine
- Increase cardiac contractility
2. Peripheral vasodilator
Name 1 effect of norepinheprine
- Potent vasoconstriction
No significant effect on cardiac contractility
Name 3 effects of milirinone
- ↑ cardiac contractility
- ↑ cardiac diastolic function
- Peripheral vasodilation
Classification of hemorrhagic shock
Class I <15%
Class II 15-30%
Class III 30-40%
Class IV >40%
Class I-<15%
-Normal vitals/perfusion
Class II-15-30%
- Slightly ↑HR/RR
- Normal BP
- Cool extremities
Class III-30-40%
-Decreased BP
Class IV->40%
- Absent peripheral pulses
- Weak central pulses
- Comatose
- Anuria
Name 5 steps in the management of trauma with blood loss
ABCs, monitors Vascular access Control of hemorrhage Crystalloid resuscitation PRBc resuscitation
What 4 types of injuries are caused by smoke inhalation?
- Acute asphyxia
- Thermal injury to the upper airways
- Chemical injury to the tracheobronchial tree
- Systemic poisoning due to carbon monoxide and/or cyanide
Name 4 indications for intubation in suspected inhalation injury
Stridor Increased WOB Resp distress Hypoventilation Deep burns to the face/neck Blistering or edema of the oropharynx (develops in first 24h)
Name 5 clinical manifestations of CO poisoning
Headache, N/V Malaise Altered LOC, Seziures, Coma SOB Arrhythmias/CHF Bright "cherry red" lips
How do you treat CO poisoning?
Give 100% fiO2
Consider need for hyperbaric oxygen (HBO) therapy
Is the SO2 (or % of oxyhemoglobin) over or underestimated in CO poisoning and methhemoglobinemia?
The percentage of oxyhemoglobin is overestimated in CO poisoning and methemoglobinemia
List 4 components of primary survey in trauma
Airway (C-spine)
Breathing
Circulation
Exposure + hypothermia
When should a massive hemothorax be drained?
AFTER fluid resuscitation
Name 3 clinical signs of cardiac tamponade
Decreased or muffled heart sounds
Distended neck veins from increased venous pressure
Hypotension with pulsus paradoxus (decreased pulse pressure during inspiration)
What are the 2 most common organs affected by blunt abdominal trauma?
- Spleen
2. Liver
What injuries are more common with bicycle handlebar impact or direct blow to abdomen?
- Pancreas
2. Duodenal
List 5 findings that suggest intra-abdominal injury after blunt torso trauma
Hypotension Abdominal tenderness Femur fracture Elevated liver enzymes Microscopic hematuria Initial hematocrit <30%
What is the best investigation to assess for intra-abdominal (including renal) injury in a hemodynamically stable child?
CT abdo
Name 2 injuries associated with pelvic fractures?
Urethral transection injury
Intraabdominal injury
Vascular injury
List 5 signs associatd with urinary tract injury
Hematuria
Bleeding from the urethral/vaginal meatus
Abdominal or flank pain
Flank mass/bruising
Fractured lower ribs or lumbar transverse processes
Inability to void
Perineal or scrotal hematoma
Name one type of injury that is more likely to cause kidney injury
Deceleration injury (e.g. falling)
If you suspect a urtheral injury, what 2 things should you do?
- Obtain retrograde cystourethrogram
2. DO NOT insert Foley
What diagnosis to suspect in resuscitated trauma patient with orange urine and rising Cr?
Rhabdomyolysis
How do you treat rhabdomyolysis?
1) Manage fluid and electrolyte abnormalities
2) Dialysis for RF
3) IV hydration with NS
4) Prevention of intratubular cast formation:
•Mannitol: protects against heme-pigment induced ATN; mechanism unknown
•Bicarbonate: forces alkaline diuresis
5) Calcium supplementation
6) Loop diuretics
List 3 signs of raised ICP in an infant
Macrocephaly Bulging anterior fontanelle ∆ LOC Splayed sutures “sunsetting” eyes
What is the initial management of suspected pelvic fracture?
Immediate external fixation (stabilizing device or sheet)
Ortho
List 4 signs suggestive of urethral injury
Scrotal/labial ecchymoses
Blood at meatus
Gross Hematuria
Superiorly positioned prostate on DRE
After how many hours post-trauma can pulmonary contusion present?
24 hours
List 4 pulmonary complications of femur fractures
PE
Fat embolism
ARD
Pneumonia.
How long after fracture does fat embolism typically present?
Usually after 24-72h
How do you diagnose fat embolism?
Clinical-• Hypoxemia, dyspnea, tachypnea, petechiael rash, neurologic changes
CXR normal
CT may show focal ground glass opacities
Name 3 ECG findings in PE
Sinus tachycardia
ST ∆
RBBB
S1Q3T3
What is the diagnostic test of choice for PE?
Spiral CT
List 3 signs of tension PTX
Asymmetric chest rise
Contralateral tracheal deviation, ↓ breath sounds on ipsilateral side
Distended neck veins
Pulsus paradoxus (↓ SBP, pulse during inspiration)
Shock
Describe how to perform needle thoracostomy
- 14-16 gauge angiocath attached to 5-10 cc syringe
- Insert into 2rd IC space MCL until air aspirated - > withdraw needle and leave angiocath open to air awaiting rush of air
Where do you insert chest tube?
Most in AAL/MAL, 4th-8th IC space
What 2 physiologic changes occur during transport that can worsen patient status?
1) Drop in PaO2 (leads to hypoxia in patients with resp insufficiency, shock)
2) Gases expand (worsens PTX, bowel obstruction)
List 3 laboratory features of rhabdomyolysis
Elevated CK Myoglobinuria Hyperkalemia Hyperphosphatemia Hypocalcemia Hyperuricemia Metabolic Acidosis AKI
List 5 causes of rhabdomyolysis
Secondary to viral myositis Crush injury Severe electrolyte abnormalities (hypernatremia, hypophosphatemia) Hypotension Hyperthermia Prolonged immobilization Disseminated intravascular coagulation Toxins (drugs, venom) Metabolic myopathies Prolonged seizures
What is the definition of hypertensive emergency?
Severe elevation BP with End organ damage
- Brain: seizures, increased intracranial pressure
- Hypertensive Encephalopathy: lethargy, coma, seizure, cerebral edema
- Kidneys: renal insufficiency
- Eyes: papilledema, retinal hemorrhages, exudates
- Heart: heart failure
What is the definition of hypertensive urgency?
Severe elevation BP without end organ damage
List 4 investigations in hypertensive emergency
- BUN, creatinine, electrolytes and glucose
- U/A
- CBC-thrombocytopenia often associated with rheumatic disorders with significant renal involvement (eg, systemic lupus erythematosus)
- CXR and ECG (+/- Echo) to screen for cardiac hypertrophy and heart failure
- Urine Tox
- CT brain in patients with hypertensive encephalopathy to evaluate for cerebral edema, intracranial hemorrhage and stroke and to differentiate hypertensive encephalopathy from intracranial injury or mass lesion
How do you treat hypertensive emergency?
Continuous IV antihypertensives-nicardipine OR labetalol
Side effects of nicardipine and labetalol
Nicardipine-reflex tachycardia
Labetalol-flushing, dyspnea
List 3 clinical features of lightning burn
- Feathering or arborescent pattern
- Cerebral edema (delayed), ICH, seizure
- Rhabdomyolysis
- Arrythmias and respiratory failure
List 3 clinical features of high tension wire burns
Entrance/exit wounds Compartment syndrome Rhabdomyolysis ARF CNS injury common VF/arrest common
List 4 indications for hospitalizations for burns
Amount: 15% BSA, 3rd degree burns
Type: Chemical, Electrical, Inhalational, other injuries
Location: face, hands, perineum, genitals, joints
Other: Poor social situation, NAI, Pregnancy, complicated medical history
Differential diagnosis for anion gap metabolic acidosis
Methanol Uremia Diabetic ketoacidosis Paraldehyde, phenoformin Isoniazid, massive Ibuprofen, iron Lactic acidosis Ethanol, ethylene glycol Salicylates
What toxins cause elevated osmolar gap?
Ethanol
Isopropyl
Methanol
Ethylene glycol
Name 3 toxic ingestions that can cause hypoglycemia (HOBBIES)
Hypoglycemics, oral: sulfonylureas, meglitinides Other: quinine, unripe ackee fruit Beta Blockers Insulin Ethanol Salicylates (late)
Name 2 toxic ingestions that cause hypocalcemia
Ethylene glycol
Fluoride
What ECG finding is associated with dixogin poisoning?
PR interval prolongation
List 5 medications that cause QTc prolongation
Amiodarone Antipsychotics (typical and atypical) Arsenic Cisapride Citalopram and other SSRIs Clarithromycin, Erythromycin Disopyramide, Dofetilide, Ibutilide Fluconazole, ketoconazole, itraconazole Methadone Pentamadine Phenothiazines Sotalol
List 3 medications/toxins that can cause QRS prolongation
Tricyclic antidepressants Diphenhydramine Carbamazepine Cardiac glycosides Chloroquine, hydoxychloroquine Cocaine Lamotrigine Quindine, quinine, procainamide, disopyramide Phenothiazines Propoxyphene Propranolol
List 4 contraindications to activated charcoal
Cannot protect airway
Bowel perforation
Substances poorly absorbed by AC: Hydrocarbons Heavy metals (iron/lead/lithium/zinc) Caustics/acids Cyanide
Name 2 side effects of activated charcoal
Bowel perf
Constipation
Aspiration in lungs (BAD)
Name 3 ingestions in which multiple activated dose charcoal can be useful
Carbamazepine, dapsone, phenobarbital, quinine, theophylline, ASA
What is the antidote for digoxin overdose?
Digoxin-specific Fab antibodies (Digibind; Digifab)
Describe the 4 clinical stages of acetaminophen toxicity
Stage 1 (0.5-24 hours)
SYMPTOMATIC
-Anorexia, nausea, vomiting, malaise, pallor, diaphoresis
-Labs typically normal, except for acetaminophen level
Stage 2 (24-48 hours) ASYMPTOMATIC -Resolution of earlier symptoms -RUQ pain -Elevated bilirubin, prothrombin time, and hepatic enzymes -Oliguria
Stage 3 (72-96 hours) LIVER FAILURE -Peak liver function abnormalities -Fulminant hepatic failure; -MODS -Death
Stage 4 (4 days-2 weeks)
RESOLUTION
-Resolution of liver function abnormalities
-Clinical recovery precedes histologic recovery
When is NAC most effective?
Within 8 hours of ingestion
Do not give before 4 hours
List 2 side effects of NAC
Non IgE anaphylactoid reaction (stop infusion, give benadryl, restart at slower rate)
How long is NAC given for?
At least 21 hours and until the patient is clinically well with improving biochemical markers and function
List 3 medications that contain salicylate
ASA
Antidiarrheal medications
Oil of wintergreen
Pepto bismol
List the 3 pathophysilogic mechanisms of salicylate toxicity
1) Direct stimulation of the respiratory center-HYPERPNEA
2) Uncoupling of oxidative phosphorylation-LACTIC ACIDOSIS
3) Inhibition of the tricarboxylic acid cycle-LACTIC ACIDOSIS
4) Stimulation of glycolysis and gluconeogenesis-HYPERGLYCEMIA, THEN HYPOGLYCEMIA
What laboratory abnormalities do you see in salicylate overdose?
Primary respiratory alkalosis and primary, anion gap, metabolic acidosis
Hyperglycemia (early) and hypoglycemia (late)
Coagulopathy
List 3 clinical features of NSAID toxicity
Nausea, vomiting, and abdominal pain
Severe-CNS depression, AG metabolic acidosis, seizures
GI bleeding and ulcers RARE
How do you treat NSAID toxicity?
Supportive-symptoms resolve within 24 hours
Charcoal doesn’t work!
No antidote
Which beta blocker is most toxic and why?
Propanolol/sotalol-Lipophilicity and blockade of fast sodium channels
Atenolol is water soluble
List 3 clinical features of beta blocker toxicity
Bradycardia
Hypotension
Hypoglycemia in younger patients (interferes with glycogenolysis and gluconeogenesis)
List 2 tests you should do in beta blocker toxicity
ECG
Accuchecks
List 3 steps in the management of beta blocker toxicity
ABC
GI decontamination-charcoal
Glucagon
If QRS widening-NaHCO3
Describe the pathophysiologic mechanism of CCB toxicity
CCBs inhibit calcium influx into myocardial and vascular smooth muscle cells → reduced myocardial contractility and conduction and peripheral vasodilation
List 3 clinical features of CCB toxicity
Bradysrythmias
Hyperglycemia
Hypotension
Metabolic acidosis (from poor perfusion)
List 3 steps in the management of CCB toxicity
ABCs-hypotension, bradycardia
Decontamination-Charcoal
Antidote-Insulin
List 3 pathophysiologic mechanisms of iron toxicity
1) Corrosive to GI tract → Hematemesis, melena, ulceration, infarction, and perforation
2) Hypotension from:
• Massive volume losses
• Increased permeability of capillary membranes
• Venodilation mediated by free iron
3) Accumulates in liver and myocardial cells:
- Hepatotoxicity
- Coagulopathy
- Cardiac dysfunction.
4) Metabolic acidosis
- Hypovolemic shock
- Directly inhibits Krebs cycle
List two side effects of deferoxamine
Hypotension
ARDS
Yersinia sepsis
Describe the pathophysiology mechanism of TCA overdose
1) Blockage of NE and serotonin reuptake
2) Antagonism of muscarininc receptors-ANTICHOLINERGIC EFECTS a
3) Blockage of fast sodium channels-ARRYTHMIAS
List 3 steps in the management of serotonin syndrome
1) Discontinuation of all serotonergic agents
2) Supportive care
3) Sedation with Benzodiazepenes
4) If benzodiazepines and supportive care fail to improve agitation and correct vital signs, consider cyproheptadine (serotonin antagonist)
What is the most important step in management of caustic ingestion?
Airway protection
Endoscopy within 12-24 hours
What is the antidote for cholinergic toxidrome?
Atropine Pralidoxime (breaks bond b/w insecticide and enzyme)
List 3 household items that contain hydrocarbons
Glues Nail polishes Paint Paint removers Pine oil Kerosene Gasoline Furniture polish Lighter fluid
List 3 complications of hydrocarbon ingestion
Aspiration pneumonitis
Arryhtmias
Mild CNS depression
When are pneumatoceles typically seen on X-ray after hydrocarbon ingestion?
After 2-3 weeks
Name 3 long term complications of inhalant abuse
Cerebral atrophy
Neuropsychological changes Peripheral neuropathy
Kidney disease
List 2 steps in management of hydrocarbon ingestion
Respiratory support
B-blocker (esmolol) to block effects of endogenous catecholamines on sensitized myocardium
What clinical features are unique to LSD intoxication?
- Alterations in hearing and vision
(e. g. “seeing” smells and “hearing” colors) - Distortions of time.
- Delusional ideation
- Body distortion
- Suspiciousness
What clinical features are unique to MDMA?
Euphoria Teeth grinding Hyperthermia Hypertension Hyponatremia (polydipsia) Seizures Hepatotoxicity Serotonin syndrome
List 3 lab tests you would do in NSAID toxicity
Creatinine/urea
Blood gas
Electrolytes(diagnose anion gap) Ibuprofen level
List 4 clinical features of Jimson weed toxicity
ANTICHOLINERGIC Tachycardia Dry/red skin Mydriasis Hyperthermia
List 2 steps in management of Jimson weed toxicity
Skin/clothes decontamination
Physostigmine
Supportive care
List 4 characteristics of a bite that affect management (past SAQ)
(1) Deep or extensive bite → would need to consult Plastic Surgery
(2) Puncture wound or avulsed tissues associated with bite → changes wound management
(3) Source of bite (human vs animal) → treat with antibiotics and need to investigate rabies risk
(4) Age of the bite (primary closure vs delayed vs secondary) →if >24 hours should not be sutured
- Host factors: Tetanus >10 yrs?
- Biter factors: Hep B pos?
