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FRCPC > Acute Care > Flashcards

Acute Care Flashcards

1
Q

How would you prepare for intubation

A 
SOAPME
Suction
Oxygen
Airway
Pharmacology
Monitoring equipment
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2
Q

What are contraindications for succylcholine?

A 
HyperK
Neuromuscular disorder
Renal failure
Burns
Crush injury
History of malignant hyperthermia or pseudocholinesterase deficiency
Glaucoma
Penetrating globe injury
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3
Q

What ratio of blood products (RBC/FFP/cryo) do you need in a massive transfusion protocol?

A

1:1:1

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4
Q

Causes of secondary brain injury

A 
Hypotension
Hyperthermia
Seizures
Raised ICP
Hypo/hypercarbia
Hypo/hyperglycemia
Hypoxemia
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5
Q

How would you manage an intracranial bleed?

A 
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
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6
Q

If you are <8 years, are more likely to injure upper or lower C-spine?

A

Upper (C1-C3)

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7
Q

If you have parasthesiaes and tingling and C-spine x-rays and CT are normal, what is the diagnosis?

A

SCIWORA-spinal cord injury without radiographic evidence of spinal cord injury
Can see abnormalities on MRI

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8
Q

What are the NEXUS criteria for clearing the C-spine?

A 
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
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9
Q

When should you do a CT head for minor head injury? (CATCH rules)

A

Any ONE of the following:

High risk (need for intervention)

  1. GCS <15 at two hours post injury
  2. Suspected open/depressed skull fracture
  3. Worsening headache
  4. Irritability on examination

Medium risk (brain injury on CT scan)

  1. Signs of basilar skull fracture
  2. Large boggy, hematoma of scalp
  3. Dangerous mechanism (fall from >3 ft, fall from bicycle no helmet, MVA)
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10
Q

What are the indications for a CT C-spine?

A

Inadequate C-spine radiographs (3 views)
Suspcious xray findings
High index of suspicion despite normal CXR

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11
Q

How do you differentiated between pseudosubluxation of C2 vs subluxation?

A

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

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12
Q

When can you see pulmonary contusion on CXR?

A

At presentation, but can be delayed to 6-8 hours

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13
Q

How long does it take to recover from pulmonary contusion?

A

Usually 3 days

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14
Q

If there are greater than ___ rib fractures, suspect that there is other thoracic injury

A

4

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15
Q

What is the most common liver injury?

A

Hematoma
Laceration
Right hepatic lobe most commonly affected

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16
Q

In a trauma, after how many boluses should you order blood

A

2

10 cc/kg pRBC

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17
Q

Indications for surgery in trauma

A

Hemodynamic instability
Major vascular injury
Major penetrating trauma
Injury to bowel, bladder or mesentery

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18
Q

What injuries are associated with a lap belt injury?

A

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
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19
Q

What heals faster metaphyseal/growth plate fractures or diaphyseal fractures?

A

Metaphyseal/growth plate # heal in half the time

Due to increased vascularity

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20
Q

What fractures are unique to children?

A 
Greenstick
Buckle
Bowing
Avulsion
Salter Harris (IV needs surgical intervention; III sometimes)
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21
Q

How do you manage clavicular fractures?

A

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

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22
Q

How do you assess neurovascular status in upper limbs?

A 
Pulse
Capillary refill
Motor and sensory:
-Radial: lateral dorsal hand, thumbs up
-Ulnar: lateral ventral hand, spreading fingers
-Median: medial ventral hand, OK
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23
Q

What 4 things are you looking for on an elbow xray?

A

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

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24
Q

What is a monteggia fracture?

A

MUGER
Ulnar fracture
Radial head dislocation

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25
Q

What are complications associated with monteggia fracture?

A

Compartment syndrome
Median/radial nerve injury
Delayed reduction

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26
Q

What is a galleazi fracture

A

MUGER
Radial fracture
Ulnar head dislocation

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27
Q

How do you treat buckle fractures?

A

Immobilize in removable splint

Remove in 3-6 weeks

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28
Q

How do you diagnose SCFE on hip x-ray?

A

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

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29
Q

How does SCFE typical present?

A

Obese adolescent male
Chronic hip/thigh/knee pain
25% are bilaterally

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30
Q

How do you treat toxic alcohol ingestion (methanol/ethylene glycol/isopropanol)?

A

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

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31
Q

Where do you find toxic alcohols?

A

Methanol-windshield washer fluid
Ethylene glycol-antifreeze
Isopropanol-pain remover, windshield de-icer, rubbing alcohol

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32
Q

What should you measure if you are concerned about an alcohol ingestion?

A

1) Osmolar gap
Calculated = 2xNa + glucose + urea
Measured – calculated = normally 0-5

2) Anion gap
Na-HCO3-Cl
Normal=8-12

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33
Q

What are the features of ethanol ingestion?

A 
Hypoglycemia (if peak serum level ≥50 mg/dL (11 mmol/L)
Lethargy
Ataxia
Slurred speech
Hypothermia
Bradycardia
Hypotension
Respiratory depression
Sickly sweet breath
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34
Q

How do you manage ethanol ingestion?

A

Supportive
Observe x 6 hours
Check sugar

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35
Q

Which drugs can be toxic in small amounts for a 10 kg child?

A 
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)
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36
Q

What are the features of methanol ingestion?

A

Severe, refractory metabolic acidosis
Retinal damage
LATENT PERIOD

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37
Q

What are the features of Isopropyl alcohol ingestion?

A

Gastritis
CNS depression, Hyperglycemia
Hypotension
No AG

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38
Q

What are the features of ethylene glycol intoxication?

A 
Severe metabolic acidosis
Seizures
Coma
Renal damage via ca oxalate crystals 
HypoCa leading to arrythmia
Puomonary/cerebral edema
LATENT PERIOD
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39
Q

What causes an increased AG (MUDPILES)?

A 
M ethanol	
U rea
D KA	
P araldehyde
I soniazid, Iron
L actic acidosis
E thylene glycol
S alicylates
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40
Q

What is a significant iron ingestion?

A

> 60 mg/kg elemental iron

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41
Q

What are the 4 phases of iron ingestion?

A

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

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42
Q

How do you treat iron ingestion?

A

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

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43
Q

In what time frame activated charcoal most effective?

A

Most effective if given within 1 hour of ingestion

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44
Q

When should you give Ipecac or gastric lavage?

A

Never

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45
Q

For what medication overdoses should you use multidose activated charcoal?

A 
Extended release medications
Theophylline
Carbamazepine
Dapsone
Phenobarbital
Quinine
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46
Q

What investigations do you order in iron ingestion?

A 
Iron level
CBC
chemistries, BUN, creatinine
glucose
LFTs
ABG
type and cross match as needed
x-ray-may show pills
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47
Q

When should you do whole bowel irrigation for a toxic ingestion?

A
  • Sustained release tablets
  • Cocaine/heroin body stuffers
  • When charcoal not effective: e.g, iron/lead/lithium/zinc
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48
Q

What do the following serum iron levels mean in a toxic ingestion?
<350 mcg/dL
350-500 mcg/dL
>500 mcg/dL

A

<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

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49
Q

In a toxic ingestion, which medications can you see on x-ray? (CHIPES)

A 
Choral hydrate
Heavy metals
Iodides
Phenothiazines
Enteric coated pills
Sustained release medications
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50
Q

What are the symptoms of salicylate overdose?

A

Hyperpnea/tachypnea-salycylate acts at resp center in medulla
Diaphoresis
Tinnitus
Vomiting

Severe-altered LOC, seizures, hyperthermia

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51
Q

What are the goals in managing a salicylate overdose?

A

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

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52
Q

What investigations should you order in salicylate poisoning?

A 
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
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53
Q

What is a toxic dose of acetaminophen?

A

> 150 mg/kg in children

>7.5-10g in teens/adults

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54
Q

When do you take an acetaminophen level and what other tests should you order at this time?

A

4 hours
LFTs
RFTs
Coags

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55
Q

How do you manage acetaminophen overdose?

A

1) Activated charcoal if <4 hours

2) N-acetylcysteine based on Rumack-Matthew nomogram-give if tylenol >150mg/L at 4 hours

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56
Q

What are the clinical features of anticholinergic toxidrome?

A

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)

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57
Q

What are some anticholinergic medications?

A 
Antihistamines 
TCAs
Phenothiazines
Anti-parkinsonian medications
Jimsonweed 
Antispasmodic agents 
Mydriatic agents 
Bronchodilator agents (ipratropium)
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58
Q

What are the clinical features of cholinergic toxidrome?

A

Wet!
DUMBELS

Diaphoresis			
Diarrhea			
Urination			
Miosis			
Bradycardia
Bronchospasm
Emesis
Lacrimation
Salivation
Seizures
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59
Q

What are some drugs causing cholinergic toxidrome?

A

Insectiside
Physostigmine, neostigmine, pyridostigmine, edrophonium
Alzheimers meds

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60
Q

What are the clinical features of sympathomimetic toxidrome?

A

Similar to anticholinergic, but wet

Anxiety
Delusions
Paranoia
Hyperreflexia
Mydriasis
Seizures 
Piloerection
Diaphoresis
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61
Q

What are some drugs causing sypathomimetic toxidrome?

A 
LSD
PCP
Amphetamienes
Pseudoephedrine
Theophylline
Ecstasy
Cocaine
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62
Q

What is special about PCP ingestion?

A

Horizontal, vertical, or rotatory nystagmus
RIGIDITY

Other features:
AMS (eg, lethargy, irritability)
Emotional lability
Choreoathetosis
Seizures
Ataxia
Blank staring
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63
Q

How to differentiate serotonin syndrome from neuroleptic malignant syndrome and anticholinergic syndrome?

A

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

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64
Q

What are the clinical features of serotonin syndrome (triad)?

A

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

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65
Q

What medications can cause serotonin syndrome?

A 
Ecstasy
LSD
SSRI’s
MAOIs
Linezolid
Tramadol
Meperidone
Valproate
Fentanyl
Ondansetron
Metoclopramide
Sumatriptan
Dextromethorphan
Dietary  and herbal products: St. John’s wort, ginseng
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66
Q

What are the clinical features of GHB?

A

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

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67
Q

How do you treat GHB ingestion?

A

Supportive-airway
Atropine for severe bradycardia
Monitor for 4-6 hours

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68
Q

What specific drugs can you ask for levels for in a suspected ingestion?

A 
ASA
Acetaminophen
Ethanol
Digoxin
Iron
Lithium
Theophylline
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69
Q

What general investigations do you order in a suspected ingestion?

A 
ECG
Serum electrolytes
Serum osmolality
ABG
AG and osmolar gap
Urine tox
Specific drug levels
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70
Q

What ECG abnormalities do you see in TCA overdose?

A

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)

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71
Q

What are your management priorities in a TCA overdose?

A

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

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72
Q

What are the three types of toxicity in TCA overdose and what are the associated symptoms?

A

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

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73
Q

What are side effects of PGE1?

A 
Apnea
Bradycardia
Hypotension
Seizures
Fever
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74
Q

How do you perform a hyperoxia test?

A

Take PaO2 in room air
Administer 100% O2
Repeat PaO2->100=normal

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75
Q

When do neonates with HSV typically present?

A

4-7 days of life

HSV encephalitis-7-21 days

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76
Q

Explain the pathophysiology of methemoglobinemia

A

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%

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77
Q

List 6 causes of methemoglobinemia

A

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

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78
Q

What are the clinical features of galactosemia (cannot convert galactose to glucose)?

A 
Vomiting
Diarrhea
FTT
Jaundice (conjugated hyperbili)
Cataracts
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79
Q

How do you treat galactosemia?

A

Treat hypoglycemia dn shock

Lactose free formula (e.g. nutamigen)

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80
Q

How do urea cycle defects present?

A

Poor feeding
Hypotonia,
Seizures
Hepatomegaly without liver failure

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81
Q

How do you treat UCD?

A

Glucose D10NS 2x maintenance (stimulates insulin and decrases protein catabolism)

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82
Q

How remove nasal foreign body?

A

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

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83
Q

How do you treat an embedded earing?

A 
Inject lidocaine
Make small incision 
Remove stud with stud with forceps/probe
Irrigate well
Discharge with antibiotics
No earring x 6-8 weeks
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84
Q

How do you treat a subungal hematoma?

A

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

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85
Q

After what time period is nail trephination for subungal hematoma unlikely to be successful?

A

48 hours

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86
Q

What is paronychia?

A

Superficial infection of the skin bordering base of the nail fold

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87
Q

How do you treat paronychia?

A

If no pus-warm soaks, elevation, antibiotics
If pus
-Need to drain; can use scalpel along side of nail
-May need digital block

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88
Q

What is the maximum dose of lidocaine you can use with and without epinephrine?

A

With epinephrine 7 mg/kg

Without epinephrine 5 mg/kg

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89
Q

How much do you irrigate a wound before you suture it?

A

100 ml per cm

Use 18G angiocath

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90
Q

If you are putting in non-absorbable sutures, how long do you keep them in for?

A

5-7 days

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91
Q

What are contraindications to using tissue glue?

A 
Infected wound
Deep wound (e.g. cat bite)
Edges do not approximate well
Near to eye 
Mucous membranes
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92
Q

How do you manage laceration to hand/foot with glass?

A 
X-ray to rule out retained glass
Check neurovascular status
Check for tendon injury
Assess tetanus tatus
Refer to plastics if tendon/neurovascular injury
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93
Q

How do you manage a dog bite?

A

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

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94
Q

Which animals are at highest risk of carrying rabies?

A 
Stray dogs
Cats
Skunks
Raccoons
Foxes
Bats-must have direct contact
Cattle
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95
Q

What is rabies prophylaxis?

A

Rabies Ig now

Rabies vaccine day 0, 3, 7, 14

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96
Q

List 3 signs of penetrating globe injury

A

Tear drop pupil
Hyphema
360 degree subconjunctival hemorrhage

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97
Q

How do you manage penetrating globe injury?

A 
Shield eye (no patching, no fluorescein)
Urgent referral to Optho
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98
Q

What are signs of corneal abrasion?

A

Photophobia
Foreign body sensation
Tearing

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99
Q

How do you diagnose corneal abrasion?

A

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

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100
Q

How do you treat corneal abrasion?

A

Evert eyelid and remove FB with cotton swab

Pressure patch

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101
Q

Name 5 things you will assess about a burn to determine management

A 
Total body surface area
Depth of burn, +/- blistering
Involvement of hands, feet, genitalia
Circumferential burn
Pattern of burn suggestive of abuse
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102
Q

What is parkland formula (for >10% TBSA) ?

A

4cc/kg/%TBSA burn

1/2 in first 8 hours; remaining in 16 hours

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103
Q

How do you diagnose methemoglobinemia?

A
  • Hypoxia that doesn’t improve with high fiO2
  • Cyanosis in the presence of a normal PaO2 – “Saturation Gap”
  • Measure metHb %
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104
Q

Why is pulse oximetry inaccurate in methemoglobinemia?

A

Pulse oximetry only measures normal oxyhemoglobin and total hemoglobin

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105
Q

List 5 management steps for methemoglobinemia

A
  1. Stop the offending agent
  2. 100% O2
  3. If <20% metHgb → observe
  4. If >20% metHgb → methylene blue
  5. If in shock → Transfusion of PRBCs or Exchange Transfusion, Hyperbaric O2
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106
Q

Name one contraindication to methylene blue

A

G6PD deficiency (can use ascorbic acid instead)

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107
Q

Name 4 indications for intubation in inhalation injury

A
  • Stridor
  • Increased WOB
  • Resp distress
  • Hypoventilation
  • Deep burns to the face/neck
  • Blistering or edema of the oropharynx (develops in first 24h)
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108
Q

Name 5 symptoms of CO poisoning

A 
Headache, N/V
Malaise
Altered LOC, Seziures, Coma
SOB
Arrhythmias/CHF
Bright "cherry red" lips
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109
Q

How do you treat CO poisoning?

A

Give 100% fiO2

Consider need for hyperbaric oxygen (HBO) therapy

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110
Q

What two types of poisoning should you suspect in inhalation injury?

A

CO

Cyanide

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111
Q

How do children get cyanide poisoning?

A

Hydrogen cyanide is a byproduct of burning certain compounds (e.g, plastic, nylon, wool, cotton)

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112
Q

What is the pathophysiology of cyanide poisoning?

A

Inhibits aerobic metabolism and can rapidly result in death

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113
Q

Name 5 clinical features of cyanide poisoning

A 
Coma
Central apnea
Cardiac dysfunction
Severe lactic acidosis
High mixed venous O2
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114
Q

How do you treat cyanide poisoning?

A

High flow O2
Decontamination
Antidotes (e.g. sodium thiosulfate + hydroxocobalamin)

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115
Q

List 3 causes of lactic acidosis in a burn patient

A

CO poisoning
Cyanide poisoning
Hypoxemia
Tissue necrosis

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116
Q

Describe the mechanism by which ORS works

A

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

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117
Q

What is the ideal composition of ORS?

A

Low osmolarity-200-250 mOsm/L

Na 45-50 mmol/L

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118
Q

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
A

> 10%

119
Q

What is the % dehydration?

Slightly decreased urine output
Slightly increased thirst
Slightly dry mucous membrane
Slightly elevated heart rate

A

<5%

120
Q

What is the % dehydration?

Decreased urine output
Moderately increased thirst
Dry mucous membrane
Elevated heart rate
Decreased skin turgor
Sunken eyes
Sunken anterior fontanelle
A

5-10%

121
Q

How much fluid should you give a patient with mild dehydration (<5%)?

A

1) Rehydrate with ORS 50 ml/kg over 4 hours
2) Replace losses with ORS
3) Age appropriate diet after rehydration

122
Q

How much fluid should you give a patient with mild dehydration (5-10%)?

A

1) Rehydrate with ORS 100 ml/kg over 4 hours
2) Replace ongoing losses with ORS
3) Age appropriate diet after rehydration

123
Q

How much fluid should you give a patient with mild dehydration (>10%)?

A

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

124
Q

Why should alternatives to ORT be discouraged (juice, carbonated drinks)?

A

Increased carbs, decreased electrolytes, increased osmolarity; can cause osmotic diarrhea

125
Q

Name 3 contraindications to ORT

A 
Prolonged vomiting despite small freq amounts
Severe dehydration
Impaired LOC
Paralytic ileus
Monosaccharide malabsorption
126
Q

Should breastfeeding be continued during rehydration?

A

YES
Early refeeding is beneficial

↑ absorption nutrients, enhances lyte replacement, ↓ diarrhea duration

127
Q

In what age group is single dose ondansetron most effective for mild/moderate dehydration? (CPS)

A

6 months to 12 years

128
Q

What should be the endpoints guiding resuscitation in shock?

A

HR
U/O (to 1 mL/kg/hr)
Cap refill (to <2 sec)
Mental status

129
Q

What happens if IV phenytoin extravasates?

A

Purple glove (edema, discoloration and pain) b/c of pH

130
Q

Name 3 side effects of fosphenytoin

A

Cardiac arrhythmias
Bradycardia
Hypotension

131
Q

Which AED is less effective if seizure is refractory to benzodiazepines?

A

Phenobarbitol (similar mechanism of action as benzodiazepines)

132
Q

Name 2 situations in which phenobarbitol should be used as a first line AED

A

Neonates

Patients on maintenance phenytoin

133
Q

List 3 most common triggers for asthma exacerbations

A

Viral URTIs
Exposure to allergens
Poor control

134
Q

Name 5 side effects of ventolin

A

Tachycardia
Low K+
Hyperglycemia
Lactic acidosis

135
Q

During what time frame should atrovent be used?

A

Only evidence for use in 1st hour with reduced hospital admission and better lung function

136
Q

When should MgSO4 be given in acute asthma?

A

Moderate and severe acute asthma, if no response during first 1-2 hours of treatment

137
Q

Name 2 side effects of MgSO4

A

Hypotension

Bradycardia

138
Q

Name 2 serious complications in asthmatics who are intubated and ventilated

A

Pneumonthorax

Impaired venous return and cardiovascular collapse

139
Q

List one risk associated with IV salbutamol

A

Arrythmia

140
Q

How many puffs of salbutamol should be given via MDI based on weight?

A

<20 kg = 5 puffs

>20 kg =10 puffs

141
Q

Describe the clinical features of Reyes syndrome

A

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

142
Q

Name 3 laboratory abnormalities in Reyes syndrome

A

Elevated LFTs
Increased PTT
Hyperammonemia, Hypoglycemia
Metabolic acidosis

143
Q

Describe the clinical features of hemorrhagic shock and encephalitis syndrome?

A 
Fever 
Shock
Diarrhea
Seizures
Hemorrhage
Evidence of DIC
Microbiologic cultures negative
144
Q

List 5 risk factors for drowning

A 
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)
145
Q

What are the 3 categories of injury in drowning?

A

Anoxic Ischemic Injury
Pulmonary Injury
Hypothermia

146
Q

What is the body’s initial response to drowning?

A

Laryngospasm

147
Q

What is the most common cause of mortality in drowning?

A

Anoxic brain injury

148
Q

List 5 end organ effects of submersion injury

A

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

149
Q

List 6 evidence-based interventions for preventing drowning

A

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
150
Q

List 5 poor prognostic signs in drowning

A

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

151
Q

List 5 good prognostic signs in drowning

A 
Immediate bystander CPR
Submersion <5 mins
Pupils equal and reactive at scene, GCS >15
Normal sinus rhythm at scene
ROSC <10 mins
152
Q

Describe the pathophysiology of drowning

A
  1. Breath holding
  2. Larygnospasm
  3. Hypoxia, hypercapnia, acidosis
  4. Airway reflexes abate and aspiration occurs
  5. Surfactant dysfunction, atelectasis
  6. Bradycardia, MODS
153
Q

List the management steps in drowning

A
  1. 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
  2. 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
  3. Hypothermia
    - Passive rewarming if T34-36
    - Active external rewarming if T30-34
    - Active internal rewarming if T<30
154
Q

What is the definition of hypothermia?

A

<35C

155
Q

Name 3 complications of hypothermia

A 
Hypocalcemia
Hypoglycemia
Hypokalemia
Metabolic acidosis
Arrhythmia
Pancreatitis!
156
Q

Name 3 clinical features of hypothemia
31-32C
28-31C
<28C

A 
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
157
Q

Below what temperature are shocks and drugs ineffective?

A

T<30C

158
Q

List 10 methods of rewarming

A

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
159
Q

When should you think about C-spine precautions in a drowning patient?

A
  • Diving
  • Alcohol or other substances
  • Trauma
160
Q

When should resuscitation be discontinued in drowning?

A

Rewarm until temp is 32-34

If no effective rhythm by 25-30 mins, then stop CPR

161
Q

What condition should you think about infant who is lethargic and has a seizure after swimming lesson?

A

Water intoxication (hypoNa(

162
Q

What equipment do you need for intubation?

A 
Call help (RT, nurses)
Monitors
O2
Suction
Laryngoscope
Appropriate size blade
ETT (0.5 size smaller and larger)
CO2 detector
Intubation medications
163
Q

Formula for ETT depth of insertion

A

3 x ETT diameter

164
Q

What blades sizes are appropriate for

a) Newborn
b) Infant/small child
c) Child
d) Adolescent/adult

A

a) Newborn-0
b) Infant/small child-1
c) Child-2
d) Adolescent/adult-2

165
Q

List 4 ways you can confirm correct placement of ETT initially

A
  1. Calormetric CO2 detector
  2. Equal breath sounds, mist in ETT
  3. ETT visualized passing through cords at glottic marker
  4. Good waveform on continuous end-tidal capnography
  5. Symmetric chest rise
166
Q

Name 4 indications for intubation

A
  1. Unable to maintain airway patency
  2. Unable to protect against aspiration
    a. GCS <8
    b. Facial trauma
    c. Airway edema/constriction
    d. Tumour/mass blocking airway
  3. Failing to maintain adequate oxygenation
    a. WOB
  4. Failing to maintain ventilation (hypercarbia)
    a. Apnea, loss of respiratory drive
  5. Sedation/paralysis required for procedure
167
Q

List 3 complications of high PEEP

A
  1. Reduced preload (decreases cardiac output)
  2. Elevated plateau airway pressure (increases risk of barotrauma and pneumothorax)
  3. Impaired cerebral venous outflow (increases intracranial pressure)
168
Q

Patient has flexion posturing, moans to painful stimuli and will not open her eyes to painful stimuli. What is GCS?

A

E1V2M3=6

169
Q

List 5 characteristics of good quality CPR

A
  • 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
170
Q

Recommended ratio of compressions:breaths in single rescuer CPR

A

30:2

171
Q

Recommended ratio of compressions:breaths in 2 rescuer CPR

A

15:2

172
Q

Recommended ratio of compressions:breaths in ventilated patients?

A

Asynchronous
Chest compressions-100/min
Breaths 8-10/min

173
Q

What 4 things should you think about in a deterioriating intubated patient?

A

Displacement of the tube
Obstruction of the tube
Pneumothorax
Equipment failure

174
Q

What is the recommended method and dose of initial defibrillation?

A

Manual defibrillation

2J/kg, then 4J/kg

175
Q

Definition of hypotension

A

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

176
Q

What should you do for a choking infant with severe obstruction (cannot cough or make a sound)?

A

5 back blows, 5 chest compressions until object expelled or patient unconscious

177
Q

What should you do for a choking child with severe obstruction (cannot cough or make a sound)?

A

Subdiaphragmatic abdominal thrusts (Heimlich maneuver) until the object is expelled or the victim becomes unresponsive

178
Q

What should be done for a choking patient who is unresponsive?

A

Chest compressions x 30
Check for object in mouth
Give 2 breaths
Repeat

179
Q

Treatment for torsades?

A

MgSO4

180
Q

Name 2 indications for atropine in bradycardic arrest

A

Primary AV block

Increased vagal tone

181
Q

Resuscitation dose of epinephrine

A

IV dose
Epinephrine 0.01 mg/kg (0.1mL) 1:10,000

ETT dose
0.1 mg/kg 1:1000

182
Q

List 2 contraindications of adenosine in tachycardia

A

Wide complex tachycardia

WPW

183
Q

What is the next step in patients with unstable tachycardia who fail adenosine and/or synchronized cardioversion?

A

Amiodarone

184
Q

Target sats post resuscitation

A

94-99%

185
Q

List 5 components of post resuscitation care

A

Maintain SO2 94-99%
Consider inotropic support/fluids
Treat seizures, agitation, hypoglycemia
Consider therapeutic hypothermia

186
Q

Name 4 criteria required for neurologic determination of death

A
  1. Established etiology capable of causing neurological death in the absence of reversible conditions capable of mimicking neurological death
  2. Deep unresponsive coma with bilateral absence of motor responses, excluding spinal reflexes
  3. 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

  1. Absent confounding factors
187
Q

Guidelines for timing of physical exam for NDD:
Newborns
Infants (30 days- 1 year)
Children (>1 year)

A

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

188
Q

In the setting of hypoxic-encepholapathic injury, when should NDD exam take place?

A

> 24H post injury

189
Q

What are the components of the physical exam in NDD?

A
  • 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
190
Q

What is a positive apnea test?

A

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

191
Q

In what situations do you do ancillary testing for NDD?

A
  • When apnea test impossible (e.g. ARDS, hypoxia)
  • Do cerebral blood flow by angiography or radionuclide scan
  • NO EEG
192
Q

Name 3 contraindications to organ donation

A 
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
193
Q

Is NDD required for organ donation?

A

No, but on exam assume YES

Can also have donation after circulatory determination of death

194
Q

List 5 reversible causes of coma

A 
Metabolic disorders
Meds, toxins
Hypothermia
Hypoxia
Hypotension/shock, Hypoglycemia/hyperglycemia, Seizure
Electrolyte abnormalities
Sepsis/meningitis/encephalitis
Bleed or brainstem lesions
195
Q

Name 5 criteria for organ donation

A

●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)

196
Q

What infusion should not be used for long term sedation?

A

Propofol

Propofol infusion syndrome-metabolic acidosis, rhabdo, death

197
Q

List the SIRS criteria

A

2/4 of (≥1* required):

  • Temp >38.5, or <36
  • WBCs ↑ or ↓ or left shift >10%
  • Tachycardia or bradycardia
  • Tachypnea
198
Q

pRBC transfusion threshold for sepsis?

A

Hb 100

199
Q

What is the definition of ARDS?

A

PaO2/FiO2 <200

200
Q

List 2 effects of dopamine

A
  1. ↑ Cardiac contractility

2. Significant peripheral vasoconstriction at >10 µg/kg/min

201
Q

Name one side effect of dopamine at higher doses?

A

Increased risk of arrythmias

202
Q

List 3 effects of epinephrine

A
  1. ↑ HR
  2. ↑ cardiac contractility
  3. Potent vasoconstrictor
203
Q

Name 3 side effects of epinephrine at high doses

A

May ↓ renal perfusion at high doses
↑ Myocardial O2 consumption
Risk arrhythmia at high doses

204
Q

Name 2 effects of dobutamine

A
  1. Increase cardiac contractility

2. Peripheral vasodilator

205
Q

Name 1 effect of norepinheprine

A
  1. Potent vasoconstriction

No significant effect on cardiac contractility

206
Q

Name 3 effects of milirinone

A
  1. ↑ cardiac contractility
  2. ↑ cardiac diastolic function
  3. Peripheral vasodilation
207
Q

Classification of hemorrhagic shock

Class I <15%
Class II 15-30%
Class III 30-40%
Class IV >40%

A

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
208
Q

Name 5 steps in the management of trauma with blood loss

A 
ABCs, monitors
Vascular access
Control of hemorrhage
Crystalloid resuscitation
PRBc resuscitation
209
Q

What 4 types of injuries are caused by smoke inhalation?

A
  1. Acute asphyxia
  2. Thermal injury to the upper airways
  3. Chemical injury to the tracheobronchial tree
  4. Systemic poisoning due to carbon monoxide and/or cyanide
210
Q

Name 4 indications for intubation in suspected inhalation injury

A 
Stridor
Increased WOB
Resp distress
Hypoventilation
Deep burns to the face/neck
Blistering or edema of the oropharynx (develops in first 24h)
211
Q

Name 5 clinical manifestations of CO poisoning

A 
Headache, N/V
Malaise
Altered LOC, Seziures, Coma
SOB
Arrhythmias/CHF
Bright "cherry red" lips
212
Q

How do you treat CO poisoning?

A

Give 100% fiO2

Consider need for hyperbaric oxygen (HBO) therapy

213
Q

Is the SO2 (or % of oxyhemoglobin) over or underestimated in CO poisoning and methhemoglobinemia?

A

The percentage of oxyhemoglobin is overestimated in CO poisoning and methemoglobinemia

214
Q

List 4 components of primary survey in trauma

A

Airway (C-spine)
Breathing
Circulation
Exposure + hypothermia

215
Q

When should a massive hemothorax be drained?

A

AFTER fluid resuscitation

216
Q

Name 3 clinical signs of cardiac tamponade

A

Decreased or muffled heart sounds

Distended neck veins from increased venous pressure

Hypotension with pulsus paradoxus (decreased pulse pressure during inspiration)

217
Q

What are the 2 most common organs affected by blunt abdominal trauma?

A
  1. Spleen

2. Liver

218
Q

What injuries are more common with bicycle handlebar impact or direct blow to abdomen?

A
  1. Pancreas

2. Duodenal

219
Q

List 5 findings that suggest intra-abdominal injury after blunt torso trauma

A 
Hypotension
Abdominal tenderness
Femur fracture
Elevated liver enzymes
Microscopic hematuria
Initial hematocrit <30%
220
Q

What is the best investigation to assess for intra-abdominal (including renal) injury in a hemodynamically stable child?

A

CT abdo

221
Q

Name 2 injuries associated with pelvic fractures?

A

Urethral transection injury
Intraabdominal injury
Vascular injury

222
Q

List 5 signs associatd with urinary tract injury

A

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

223
Q

Name one type of injury that is more likely to cause kidney injury

A

Deceleration injury (e.g. falling)

224
Q

If you suspect a urtheral injury, what 2 things should you do?

A
  1. Obtain retrograde cystourethrogram

2. DO NOT insert Foley

225
Q

What diagnosis to suspect in resuscitated trauma patient with orange urine and rising Cr?

A

Rhabdomyolysis

226
Q

How do you treat rhabdomyolysis?

A

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

227
Q

List 3 signs of raised ICP in an infant

A 
Macrocephaly
Bulging anterior fontanelle
∆ LOC
Splayed sutures
“sunsetting” eyes
228
Q

What is the initial management of suspected pelvic fracture?

A

Immediate external fixation (stabilizing device or sheet)

Ortho

229
Q

List 4 signs suggestive of urethral injury

A

Scrotal/labial ecchymoses
Blood at meatus
Gross Hematuria
Superiorly positioned prostate on DRE

230
Q

After how many hours post-trauma can pulmonary contusion present?

A

24 hours

231
Q

List 4 pulmonary complications of femur fractures

A

PE
Fat embolism
ARD
Pneumonia.

232
Q

How long after fracture does fat embolism typically present?

A

Usually after 24-72h

233
Q

How do you diagnose fat embolism?

A

Clinical-• Hypoxemia, dyspnea, tachypnea, petechiael rash, neurologic changes

CXR normal

CT may show focal ground glass opacities

234
Q

Name 3 ECG findings in PE

A

Sinus tachycardia
ST ∆
RBBB
S1Q3T3

235
Q

What is the diagnostic test of choice for PE?

A

Spiral CT

236
Q

List 3 signs of tension PTX

A

Asymmetric chest rise
Contralateral tracheal deviation, ↓ breath sounds on ipsilateral side
Distended neck veins
Pulsus paradoxus (↓ SBP, pulse during inspiration)
Shock

237
Q

Describe how to perform needle thoracostomy

A
  • 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
238
Q

Where do you insert chest tube?

A

Most in AAL/MAL, 4th-8th IC space

239
Q

What 2 physiologic changes occur during transport that can worsen patient status?

A

1) Drop in PaO2 (leads to hypoxia in patients with resp insufficiency, shock)
2) Gases expand (worsens PTX, bowel obstruction)

240
Q

List 3 laboratory features of rhabdomyolysis

A 
Elevated CK
Myoglobinuria
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
Hyperuricemia
Metabolic Acidosis
AKI
241
Q

List 5 causes of rhabdomyolysis

A 
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
242
Q

What is the definition of hypertensive emergency?

A

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
243
Q

What is the definition of hypertensive urgency?

A

Severe elevation BP without end organ damage

244
Q

List 4 investigations in hypertensive emergency

A
  • 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
245
Q

How do you treat hypertensive emergency?

A

Continuous IV antihypertensives-nicardipine OR labetalol

246
Q

Side effects of nicardipine and labetalol

A

Nicardipine-reflex tachycardia

Labetalol-flushing, dyspnea

247
Q

List 3 clinical features of lightning burn

A
  • Feathering or arborescent pattern
  • Cerebral edema (delayed), ICH, seizure
  • Rhabdomyolysis
  • Arrythmias and respiratory failure
248
Q

List 3 clinical features of high tension wire burns

A 
Entrance/exit wounds
Compartment syndrome
Rhabdomyolysis
ARF
CNS injury common
VF/arrest common
249
Q

List 4 indications for hospitalizations for burns

A

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

250
Q

Differential diagnosis for anion gap metabolic acidosis

A 
Methanol
Uremia
Diabetic ketoacidosis
Paraldehyde, phenoformin
Isoniazid, massive Ibuprofen, iron
Lactic acidosis
Ethanol, ethylene glycol
Salicylates
251
Q

What toxins cause elevated osmolar gap?

A

Ethanol
Isopropyl
Methanol
Ethylene glycol

252
Q

Name 3 toxic ingestions that can cause hypoglycemia (HOBBIES)

A 
Hypoglycemics, oral: sulfonylureas, meglitinides
Other: quinine, unripe ackee fruit
Beta Blockers
Insulin
Ethanol
Salicylates (late)
253
Q

Name 2 toxic ingestions that cause hypocalcemia

A

Ethylene glycol

Fluoride

254
Q

What ECG finding is associated with dixogin poisoning?

A

PR interval prolongation

255
Q

List 5 medications that cause QTc prolongation

A 
Amiodarone
Antipsychotics (typical and atypical)
Arsenic
Cisapride
Citalopram and other SSRIs
Clarithromycin, Erythromycin
Disopyramide, Dofetilide, Ibutilide
Fluconazole, ketoconazole, itraconazole
Methadone
Pentamadine
Phenothiazines
Sotalol
256
Q

List 3 medications/toxins that can cause QRS prolongation

A 
Tricyclic antidepressants
Diphenhydramine
Carbamazepine
Cardiac glycosides
Chloroquine, hydoxychloroquine
Cocaine
Lamotrigine
Quindine, quinine, procainamide, disopyramide
Phenothiazines
Propoxyphene
Propranolol
257
Q

List 4 contraindications to activated charcoal

A

Cannot protect airway

Bowel perforation

Substances poorly absorbed by AC:
Hydrocarbons
Heavy metals (iron/lead/lithium/zinc)
Caustics/acids
Cyanide
258
Q

Name 2 side effects of activated charcoal

A

Bowel perf
Constipation
Aspiration in lungs (BAD)

259
Q

Name 3 ingestions in which multiple activated dose charcoal can be useful

A

Carbamazepine, dapsone, phenobarbital, quinine, theophylline, ASA

260
Q

What is the antidote for digoxin overdose?

A

Digoxin-specific Fab antibodies (Digibind; Digifab)

261
Q

Describe the 4 clinical stages of acetaminophen toxicity

A

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

262
Q

When is NAC most effective?

A

Within 8 hours of ingestion

Do not give before 4 hours

263
Q

List 2 side effects of NAC

A

Non IgE anaphylactoid reaction (stop infusion, give benadryl, restart at slower rate)

264
Q

How long is NAC given for?

A

At least 21 hours and until the patient is clinically well with improving biochemical markers and function

265
Q

List 3 medications that contain salicylate

A

ASA
Antidiarrheal medications
Oil of wintergreen
Pepto bismol

266
Q

List the 3 pathophysilogic mechanisms of salicylate toxicity

A

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

267
Q

What laboratory abnormalities do you see in salicylate overdose?

A

Primary respiratory alkalosis and primary, anion gap, metabolic acidosis

Hyperglycemia (early) and hypoglycemia (late)

Coagulopathy

268
Q

List 3 clinical features of NSAID toxicity

A

Nausea, vomiting, and abdominal pain

Severe-CNS depression, AG metabolic acidosis, seizures

GI bleeding and ulcers RARE

269
Q

How do you treat NSAID toxicity?

A

Supportive-symptoms resolve within 24 hours
Charcoal doesn’t work!
No antidote

270
Q

Which beta blocker is most toxic and why?

A

Propanolol/sotalol-Lipophilicity and blockade of fast sodium channels
Atenolol is water soluble

271
Q

List 3 clinical features of beta blocker toxicity

A

Bradycardia
Hypotension
Hypoglycemia in younger patients (interferes with glycogenolysis and gluconeogenesis)

272
Q

List 2 tests you should do in beta blocker toxicity

A

ECG

Accuchecks

273
Q

List 3 steps in the management of beta blocker toxicity

A

ABC
GI decontamination-charcoal
Glucagon
If QRS widening-NaHCO3

274
Q

Describe the pathophysiologic mechanism of CCB toxicity

A

CCBs inhibit calcium influx into myocardial and vascular smooth muscle cells → reduced myocardial contractility and conduction and peripheral vasodilation

275
Q

List 3 clinical features of CCB toxicity

A

Bradysrythmias
Hyperglycemia
Hypotension
Metabolic acidosis (from poor perfusion)

276
Q

List 3 steps in the management of CCB toxicity

A

ABCs-hypotension, bradycardia
Decontamination-Charcoal
Antidote-Insulin

277
Q

List 3 pathophysiologic mechanisms of iron toxicity

A

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

278
Q

List two side effects of deferoxamine

A

Hypotension
ARDS
Yersinia sepsis

279
Q

Describe the pathophysiology mechanism of TCA overdose

A

1) Blockage of NE and serotonin reuptake
2) Antagonism of muscarininc receptors-ANTICHOLINERGIC EFECTS a
3) Blockage of fast sodium channels-ARRYTHMIAS

280
Q

List 3 steps in the management of serotonin syndrome

A

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)

281
Q

What is the most important step in management of caustic ingestion?

A

Airway protection

Endoscopy within 12-24 hours

282
Q

What is the antidote for cholinergic toxidrome?

A 
Atropine
Pralidoxime (breaks bond b/w insecticide and enzyme)
283
Q

List 3 household items that contain hydrocarbons

A 
Glues
Nail polishes
Paint
Paint removers
Pine oil
Kerosene
Gasoline
Furniture polish
Lighter fluid
284
Q

List 3 complications of hydrocarbon ingestion

A

Aspiration pneumonitis
Arryhtmias
Mild CNS depression

285
Q

When are pneumatoceles typically seen on X-ray after hydrocarbon ingestion?

A

After 2-3 weeks

286
Q

Name 3 long term complications of inhalant abuse

A

Cerebral atrophy
Neuropsychological changes Peripheral neuropathy
Kidney disease

287
Q

List 2 steps in management of hydrocarbon ingestion

A

Respiratory support

B-blocker (esmolol) to block effects of endogenous catecholamines on sensitized myocardium

288
Q

What clinical features are unique to LSD intoxication?

A
  • Alterations in hearing and vision
    (e. g. “seeing” smells and “hearing” colors)
  • Distortions of time.
  • Delusional ideation
  • Body distortion
  • Suspiciousness
289
Q

What clinical features are unique to MDMA?

A 
Euphoria
Teeth grinding
Hyperthermia
Hypertension
Hyponatremia (polydipsia)
Seizures
Hepatotoxicity
Serotonin syndrome
290
Q

List 3 lab tests you would do in NSAID toxicity

A

Creatinine/urea
Blood gas
Electrolytes(diagnose anion gap) Ibuprofen level

291
Q

List 4 clinical features of Jimson weed toxicity

A 
ANTICHOLINERGIC
Tachycardia
Dry/red skin
Mydriasis
Hyperthermia
292
Q

List 2 steps in management of Jimson weed toxicity

A

Skin/clothes decontamination
Physostigmine
Supportive care

293
Q

List 4 characteristics of a bite that affect management (past SAQ)

A

(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?

FRCPC (27 decks)

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