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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
What are complications associated with monteggia fracture?
Compartment syndrome Median/radial nerve injury Delayed reduction
26
What is a galleazi fracture
MUGER Radial fracture Ulnar head dislocation
27
How do you treat buckle fractures?
Immobilize in removable splint | Remove in 3-6 weeks
28
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
29
How does SCFE typical present?
Obese adolescent male Chronic hip/thigh/knee pain 25% are bilaterally
30
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
31
Where do you find toxic alcohols?
Methanol-windshield washer fluid Ethylene glycol-antifreeze Isopropanol-pain remover, windshield de-icer, rubbing alcohol
32
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
33
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 ```
34
How do you manage ethanol ingestion?
Supportive Observe x 6 hours Check sugar
35
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) ```
36
What are the features of methanol ingestion?
Severe, refractory metabolic acidosis Retinal damage LATENT PERIOD
37
What are the features of Isopropyl alcohol ingestion?
Gastritis CNS depression, Hyperglycemia Hypotension No AG
38
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 ```
39
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 ```
40
What is a significant iron ingestion?
>60 mg/kg elemental iron
41
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
42
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
43
In what time frame activated charcoal most effective?
Most effective if given within 1 hour of ingestion
44
When should you give Ipecac or gastric lavage?
Never
45
For what medication overdoses should you use multidose activated charcoal?
``` Extended release medications Theophylline Carbamazepine Dapsone Phenobarbital Quinine ```
46
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 ```
47
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
48
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
49
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 ```
50
What are the symptoms of salicylate overdose?
Hyperpnea/tachypnea-salycylate acts at resp center in medulla Diaphoresis Tinnitus Vomiting Severe-altered LOC, seizures, hyperthermia
51
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
52
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 ```
53
What is a toxic dose of acetaminophen?
>150 mg/kg in children | >7.5-10g in teens/adults
54
When do you take an acetaminophen level and what other tests should you order at this time?
4 hours LFTs RFTs Coags
55
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
56
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)
57
What are some anticholinergic medications?
``` Antihistamines TCAs Phenothiazines Anti-parkinsonian medications Jimsonweed Antispasmodic agents Mydriatic agents Bronchodilator agents (ipratropium) ```
58
What are the clinical features of cholinergic toxidrome?
Wet! DUMBELS ``` Diaphoresis Diarrhea Urination Miosis Bradycardia Bronchospasm Emesis Lacrimation Salivation Seizures ```
59
What are some drugs causing cholinergic toxidrome?
Insectiside Physostigmine, neostigmine, pyridostigmine, edrophonium Alzheimers meds
60
What are the clinical features of sympathomimetic toxidrome?
Similar to anticholinergic, but wet ``` Anxiety Delusions Paranoia Hyperreflexia Mydriasis Seizures Piloerection Diaphoresis ```
61
What are some drugs causing sypathomimetic toxidrome?
``` LSD PCP Amphetamienes Pseudoephedrine Theophylline Ecstasy Cocaine ```
62
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 ```
63
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
64
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
65
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 ```
66
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
67
How do you treat GHB ingestion?
Supportive-airway Atropine for severe bradycardia Monitor for 4-6 hours
68
What specific drugs can you ask for levels for in a suspected ingestion?
``` ASA Acetaminophen Ethanol Digoxin Iron Lithium Theophylline ```
69
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 ```
70
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)
71
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
72
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
73
What are side effects of PGE1?
``` Apnea Bradycardia Hypotension Seizures Fever ```
74
How do you perform a hyperoxia test?
Take PaO2 in room air Administer 100% O2 Repeat PaO2->100=normal
75
When do neonates with HSV typically present?
4-7 days of life | HSV encephalitis-7-21 days
76
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%
77
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
78
What are the clinical features of galactosemia (cannot convert galactose to glucose)?
``` Vomiting Diarrhea FTT Jaundice (conjugated hyperbili) Cataracts ```
79
How do you treat galactosemia?
Treat hypoglycemia dn shock | Lactose free formula (e.g. nutamigen)
80
How do urea cycle defects present?
Poor feeding Hypotonia, Seizures Hepatomegaly without liver failure
81
How do you treat UCD?
Glucose D10NS 2x maintenance (stimulates insulin and decrases protein catabolism)
82
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
83
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 ```
84
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
85
After what time period is nail trephination for subungal hematoma unlikely to be successful?
48 hours
86
What is paronychia?
Superficial infection of the skin bordering base of the nail fold
87
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
88
What is the maximum dose of lidocaine you can use with and without epinephrine?
With epinephrine 7 mg/kg | Without epinephrine 5 mg/kg
89
How much do you irrigate a wound before you suture it?
100 ml per cm | Use 18G angiocath
90
If you are putting in non-absorbable sutures, how long do you keep them in for?
5-7 days
91
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 ```
92
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 ```
93
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
94
Which animals are at highest risk of carrying rabies?
``` Stray dogs Cats Skunks Raccoons Foxes Bats-must have direct contact Cattle ```
95
What is rabies prophylaxis?
Rabies Ig now | Rabies vaccine day 0, 3, 7, 14
96
List 3 signs of penetrating globe injury
Tear drop pupil Hyphema 360 degree subconjunctival hemorrhage
97
How do you manage penetrating globe injury?
``` Shield eye (no patching, no fluorescein) Urgent referral to Optho ```
98
What are signs of corneal abrasion?
Photophobia Foreign body sensation Tearing
99
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
100
How do you treat corneal abrasion?
Evert eyelid and remove FB with cotton swab Pressure patch
101
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 ```
102
What is parkland formula (for >10% TBSA) ?
4cc/kg/%TBSA burn | 1/2 in first 8 hours; remaining in 16 hours
103
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 %
104
Why is pulse oximetry inaccurate in methemoglobinemia?
Pulse oximetry only measures normal oxyhemoglobin and total hemoglobin
105
List 5 management steps for methemoglobinemia
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
106
Name one contraindication to methylene blue
G6PD deficiency (can use ascorbic acid instead)
107
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)
108
Name 5 symptoms of CO poisoning
``` Headache, N/V Malaise Altered LOC, Seziures, Coma SOB Arrhythmias/CHF Bright "cherry red" lips ```
109
How do you treat CO poisoning?
Give 100% fiO2 Consider need for hyperbaric oxygen (HBO) therapy
110
What two types of poisoning should you suspect in inhalation injury?
CO | Cyanide
111
How do children get cyanide poisoning?
Hydrogen cyanide is a byproduct of burning certain compounds (e.g, plastic, nylon, wool, cotton)
112
What is the pathophysiology of cyanide poisoning?
Inhibits aerobic metabolism and can rapidly result in death
113
Name 5 clinical features of cyanide poisoning
``` Coma Central apnea Cardiac dysfunction Severe lactic acidosis High mixed venous O2 ```
114
How do you treat cyanide poisoning?
High flow O2 Decontamination Antidotes (e.g. sodium thiosulfate + hydroxocobalamin)
115
List 3 causes of lactic acidosis in a burn patient
CO poisoning Cyanide poisoning Hypoxemia Tissue necrosis
116
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
117
What is the ideal composition of ORS?
Low osmolarity-200-250 mOsm/L | Na 45-50 mmol/L
118
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%
119
What is the % dehydration? Slightly decreased urine output Slightly increased thirst Slightly dry mucous membrane Slightly elevated heart rate
<5%
120
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%
121
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
122
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
123
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
124
Why should alternatives to ORT be discouraged (juice, carbonated drinks)?
Increased carbs, decreased electrolytes, increased osmolarity; can cause osmotic diarrhea
125
Name 3 contraindications to ORT
``` Prolonged vomiting despite small freq amounts Severe dehydration Impaired LOC Paralytic ileus Monosaccharide malabsorption ```
126
Should breastfeeding be continued during rehydration?
YES Early refeeding is beneficial ↑ absorption nutrients, enhances lyte replacement, ↓ diarrhea duration
127
In what age group is single dose ondansetron most effective for mild/moderate dehydration? (CPS)
6 months to 12 years
128
What should be the endpoints guiding resuscitation in shock?
HR U/O (to 1 mL/kg/hr) Cap refill (to <2 sec) Mental status
129
What happens if IV phenytoin extravasates?
Purple glove (edema, discoloration and pain) b/c of pH
130
Name 3 side effects of fosphenytoin
Cardiac arrhythmias Bradycardia Hypotension
131
Which AED is less effective if seizure is refractory to benzodiazepines?
Phenobarbitol (similar mechanism of action as benzodiazepines)
132
Name 2 situations in which phenobarbitol should be used as a first line AED
Neonates | Patients on maintenance phenytoin
133
List 3 most common triggers for asthma exacerbations
Viral URTIs Exposure to allergens Poor control
134
Name 5 side effects of ventolin
Tachycardia Low K+ Hyperglycemia Lactic acidosis
135
During what time frame should atrovent be used?
Only evidence for use in 1st hour with reduced hospital admission and better lung function
136
When should MgSO4 be given in acute asthma?
Moderate and severe acute asthma, if no response during first 1-2 hours of treatment
137
Name 2 side effects of MgSO4
Hypotension | Bradycardia
138
Name 2 serious complications in asthmatics who are intubated and ventilated
Pneumonthorax | Impaired venous return and cardiovascular collapse
139
List one risk associated with IV salbutamol
Arrythmia
140
How many puffs of salbutamol should be given via MDI based on weight?
<20 kg = 5 puffs | >20 kg =10 puffs
141
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
142
Name 3 laboratory abnormalities in Reyes syndrome
Elevated LFTs Increased PTT Hyperammonemia, Hypoglycemia Metabolic acidosis
143
Describe the clinical features of hemorrhagic shock and encephalitis syndrome?
``` Fever Shock Diarrhea Seizures Hemorrhage Evidence of DIC Microbiologic cultures negative ```
144
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) ```
145
What are the 3 categories of injury in drowning?
Anoxic Ischemic Injury Pulmonary Injury Hypothermia
146
What is the body's initial response to drowning?
Laryngospasm
147
What is the most common cause of mortality in drowning?
Anoxic brain injury
148
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
149
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 ```
150
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
151
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 ```
152
Describe the pathophysiology of drowning
1. Breath holding 2. Larygnospasm 3. Hypoxia, hypercapnia, acidosis 4. Airway reflexes abate and aspiration occurs 5. Surfactant dysfunction, atelectasis 6. Bradycardia, MODS
153
List the management steps in drowning
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
What is the definition of hypothermia?
<35C
155
Name 3 complications of hypothermia
``` Hypocalcemia Hypoglycemia Hypokalemia Metabolic acidosis Arrhythmia Pancreatitis! ```
156
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 ```
157
Below what temperature are shocks and drugs ineffective?
T<30C
158
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 ```
159
When should you think about C-spine precautions in a drowning patient?
- Diving - Alcohol or other substances - Trauma
160
When should resuscitation be discontinued in drowning?
Rewarm until temp is 32-34 | If no effective rhythm by 25-30 mins, then stop CPR
161
What condition should you think about infant who is lethargic and has a seizure after swimming lesson?
Water intoxication (hypoNa(
162
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 ```
163
Formula for ETT depth of insertion
3 x ETT diameter
164
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
165
List 4 ways you can confirm correct placement of ETT initially
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
Name 4 indications for intubation
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
List 3 complications of high PEEP
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
Patient has flexion posturing, moans to painful stimuli and will not open her eyes to painful stimuli. What is GCS?
E1V2M3=6
169
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
170
Recommended ratio of compressions:breaths in single rescuer CPR
30:2
171
Recommended ratio of compressions:breaths in 2 rescuer CPR
15:2
172
Recommended ratio of compressions:breaths in ventilated patients?
Asynchronous Chest compressions-100/min Breaths 8-10/min
173
What 4 things should you think about in a deterioriating intubated patient?
Displacement of the tube Obstruction of the tube Pneumothorax Equipment failure
174
What is the recommended method and dose of initial defibrillation?
Manual defibrillation | 2J/kg, then 4J/kg
175
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
176
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
177
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
178
What should be done for a choking patient who is unresponsive?
Chest compressions x 30 Check for object in mouth Give 2 breaths Repeat
179
Treatment for torsades?
MgSO4
180
Name 2 indications for atropine in bradycardic arrest
Primary AV block | Increased vagal tone
181
Resuscitation dose of epinephrine
IV dose Epinephrine 0.01 mg/kg (0.1mL) 1:10,000 ETT dose 0.1 mg/kg 1:1000
182
List 2 contraindications of adenosine in tachycardia
Wide complex tachycardia | WPW
183
What is the next step in patients with unstable tachycardia who fail adenosine and/or synchronized cardioversion?
Amiodarone
184
Target sats post resuscitation
94-99%
185
List 5 components of post resuscitation care
Maintain SO2 94-99% Consider inotropic support/fluids Treat seizures, agitation, hypoglycemia Consider therapeutic hypothermia
186
Name 4 criteria required for neurologic determination of death
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 5. Absent confounding factors
187
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
188
In the setting of hypoxic-encepholapathic injury, when should NDD exam take place?
>24H post injury
189
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
190
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
191
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
192
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 ```
193
Is NDD required for organ donation?
No, but on exam assume YES | Can also have donation after circulatory determination of death
194
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 ```
195
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)
196
What infusion should not be used for long term sedation?
Propofol | Propofol infusion syndrome-metabolic acidosis, rhabdo, death
197
List the SIRS criteria
2/4 of (≥1* required): - Temp >38.5, or <36 - WBCs ↑ or ↓ or left shift >10% - Tachycardia or bradycardia - Tachypnea
198
pRBC transfusion threshold for sepsis?
Hb 100
199
What is the definition of ARDS?
PaO2/FiO2 <200
200
List 2 effects of dopamine
1. ↑ Cardiac contractility | 2. Significant peripheral vasoconstriction at >10 µg/kg/min
201
Name one side effect of dopamine at higher doses?
Increased risk of arrythmias
202
List 3 effects of epinephrine
1. ↑ HR 2. ↑ cardiac contractility 3. Potent vasoconstrictor
203
Name 3 side effects of epinephrine at high doses
May ↓ renal perfusion at high doses ↑ Myocardial O2 consumption Risk arrhythmia at high doses
204
Name 2 effects of dobutamine
1. Increase cardiac contractility | 2. Peripheral vasodilator
205
Name 1 effect of norepinheprine
1. Potent vasoconstriction | No significant effect on cardiac contractility
206
Name 3 effects of milirinone
1. ↑ cardiac contractility 2. ↑ cardiac diastolic function 3. Peripheral vasodilation
207
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
208
Name 5 steps in the management of trauma with blood loss
``` ABCs, monitors Vascular access Control of hemorrhage Crystalloid resuscitation PRBc resuscitation ```
209
What 4 types of injuries are caused by smoke inhalation?
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
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) ```
211
Name 5 clinical manifestations of CO poisoning
``` Headache, N/V Malaise Altered LOC, Seziures, Coma SOB Arrhythmias/CHF Bright "cherry red" lips ```
212
How do you treat CO poisoning?
Give 100% fiO2 Consider need for hyperbaric oxygen (HBO) therapy
213
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
214
List 4 components of primary survey in trauma
Airway (C-spine) Breathing Circulation Exposure + hypothermia
215
When should a massive hemothorax be drained?
AFTER fluid resuscitation
216
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)
217
What are the 2 most common organs affected by blunt abdominal trauma?
1. Spleen | 2. Liver
218
What injuries are more common with bicycle handlebar impact or direct blow to abdomen?
1. Pancreas | 2. Duodenal
219
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% ```
220
What is the best investigation to assess for intra-abdominal (including renal) injury in a hemodynamically stable child?
CT abdo
221
Name 2 injuries associated with pelvic fractures?
Urethral transection injury Intraabdominal injury Vascular injury
222
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
223
Name one type of injury that is more likely to cause kidney injury
Deceleration injury (e.g. falling)
224
If you suspect a urtheral injury, what 2 things should you do?
1. Obtain retrograde cystourethrogram | 2. DO NOT insert Foley
225
What diagnosis to suspect in resuscitated trauma patient with orange urine and rising Cr?
Rhabdomyolysis
226
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
227
List 3 signs of raised ICP in an infant
``` Macrocephaly Bulging anterior fontanelle ∆ LOC Splayed sutures “sunsetting” eyes ```
228
What is the initial management of suspected pelvic fracture?
Immediate external fixation (stabilizing device or sheet) Ortho
229
List 4 signs suggestive of urethral injury
Scrotal/labial ecchymoses Blood at meatus Gross Hematuria Superiorly positioned prostate on DRE
230
After how many hours post-trauma can pulmonary contusion present?
24 hours
231
List 4 pulmonary complications of femur fractures
PE Fat embolism ARD Pneumonia.
232
How long after fracture does fat embolism typically present?
Usually after 24-72h
233
How do you diagnose fat embolism?
Clinical-• Hypoxemia, dyspnea, tachypnea, petechiael rash, neurologic changes CXR normal CT may show focal ground glass opacities
234
Name 3 ECG findings in PE
Sinus tachycardia ST ∆ RBBB S1Q3T3
235
What is the diagnostic test of choice for PE?
Spiral CT
236
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
237
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
238
Where do you insert chest tube?
Most in AAL/MAL, 4th-8th IC space
239
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)
240
List 3 laboratory features of rhabdomyolysis
``` Elevated CK Myoglobinuria Hyperkalemia Hyperphosphatemia Hypocalcemia Hyperuricemia Metabolic Acidosis AKI ```
241
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 ```
242
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
243
What is the definition of hypertensive urgency?
Severe elevation BP without end organ damage
244
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
245
How do you treat hypertensive emergency?
Continuous IV antihypertensives-nicardipine OR labetalol
246
Side effects of nicardipine and labetalol
Nicardipine-reflex tachycardia | Labetalol-flushing, dyspnea
247
List 3 clinical features of lightning burn
- Feathering or arborescent pattern - Cerebral edema (delayed), ICH, seizure - Rhabdomyolysis - Arrythmias and respiratory failure
248
List 3 clinical features of high tension wire burns
``` Entrance/exit wounds Compartment syndrome Rhabdomyolysis ARF CNS injury common VF/arrest common ```
249
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
250
Differential diagnosis for anion gap metabolic acidosis
``` Methanol Uremia Diabetic ketoacidosis Paraldehyde, phenoformin Isoniazid, massive Ibuprofen, iron Lactic acidosis Ethanol, ethylene glycol Salicylates ```
251
What toxins cause elevated osmolar gap?
Ethanol Isopropyl Methanol Ethylene glycol
252
Name 3 toxic ingestions that can cause hypoglycemia (HOBBIES)
``` Hypoglycemics, oral: sulfonylureas, meglitinides Other: quinine, unripe ackee fruit Beta Blockers Insulin Ethanol Salicylates (late) ```
253
Name 2 toxic ingestions that cause hypocalcemia
Ethylene glycol | Fluoride
254
What ECG finding is associated with dixogin poisoning?
PR interval prolongation
255
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 ```
256
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 ```
257
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 ```
258
Name 2 side effects of activated charcoal
Bowel perf Constipation Aspiration in lungs (BAD)
259
Name 3 ingestions in which multiple activated dose charcoal can be useful
Carbamazepine, dapsone, phenobarbital, quinine, theophylline, ASA
260
What is the antidote for digoxin overdose?
Digoxin-specific Fab antibodies (Digibind; Digifab)
261
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
262
When is NAC most effective?
Within 8 hours of ingestion Do not give before 4 hours
263
List 2 side effects of NAC
Non IgE anaphylactoid reaction (stop infusion, give benadryl, restart at slower rate)
264
How long is NAC given for?
At least 21 hours and until the patient is clinically well with improving biochemical markers and function
265
List 3 medications that contain salicylate
ASA Antidiarrheal medications Oil of wintergreen Pepto bismol
266
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
267
What laboratory abnormalities do you see in salicylate overdose?
Primary respiratory alkalosis and primary, anion gap, metabolic acidosis Hyperglycemia (early) and hypoglycemia (late) Coagulopathy
268
List 3 clinical features of NSAID toxicity
Nausea, vomiting, and abdominal pain Severe-CNS depression, AG metabolic acidosis, seizures GI bleeding and ulcers RARE
269
How do you treat NSAID toxicity?
Supportive-symptoms resolve within 24 hours Charcoal doesn't work! No antidote
270
Which beta blocker is most toxic and why?
Propanolol/sotalol-Lipophilicity and blockade of fast sodium channels Atenolol is water soluble
271
List 3 clinical features of beta blocker toxicity
Bradycardia Hypotension Hypoglycemia in younger patients (interferes with glycogenolysis and gluconeogenesis)
272
List 2 tests you should do in beta blocker toxicity
ECG | Accuchecks
273
List 3 steps in the management of beta blocker toxicity
ABC GI decontamination-charcoal Glucagon If QRS widening-NaHCO3
274
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
275
List 3 clinical features of CCB toxicity
Bradysrythmias Hyperglycemia Hypotension Metabolic acidosis (from poor perfusion)
276
List 3 steps in the management of CCB toxicity
ABCs-hypotension, bradycardia Decontamination-Charcoal Antidote-Insulin
277
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
278
List two side effects of deferoxamine
Hypotension ARDS Yersinia sepsis
279
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
280
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)
281
What is the most important step in management of caustic ingestion?
Airway protection | Endoscopy within 12-24 hours
282
What is the antidote for cholinergic toxidrome?
``` Atropine Pralidoxime (breaks bond b/w insecticide and enzyme) ```
283
List 3 household items that contain hydrocarbons
``` Glues Nail polishes Paint Paint removers Pine oil Kerosene Gasoline Furniture polish Lighter fluid ```
284
List 3 complications of hydrocarbon ingestion
Aspiration pneumonitis Arryhtmias Mild CNS depression
285
When are pneumatoceles typically seen on X-ray after hydrocarbon ingestion?
After 2-3 weeks
286
Name 3 long term complications of inhalant abuse
Cerebral atrophy Neuropsychological changes Peripheral neuropathy Kidney disease
287
List 2 steps in management of hydrocarbon ingestion
Respiratory support B-blocker (esmolol) to block effects of endogenous catecholamines on sensitized myocardium
288
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
289
What clinical features are unique to MDMA?
``` Euphoria Teeth grinding Hyperthermia Hypertension Hyponatremia (polydipsia) Seizures Hepatotoxicity Serotonin syndrome ```
290
List 3 lab tests you would do in NSAID toxicity
Creatinine/urea Blood gas Electrolytes(diagnose anion gap) Ibuprofen level
291
List 4 clinical features of Jimson weed toxicity
``` ANTICHOLINERGIC Tachycardia Dry/red skin Mydriasis Hyperthermia ```
292
List 2 steps in management of Jimson weed toxicity
Skin/clothes decontamination Physostigmine Supportive care
293
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?

FRCPC (27 decks)

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