ACUTE CARE Flashcards
1
Q
A
2
Q
A patient has hypopigmented scar after minor trauma and vesicular rash in sun exposed areas. This is most likely due to which medication?
A
NSAIDs = pseudoporphyria
3
Q
A patient overdoses on cocaine is extremely agitated and a danger to himself and others. What immediate treatment would you start?
A
Benzos (used for agitation or hallucinations)
4
Q
A patient presents with an ingestion but won’t tell you what they took and are asymptomatic. What is your management plan?
A
- Supportive management 2. Observe 4-6 hours if asymptomatic -if you do eventually find out what they took, need to figure out half life and observe for at least that long
5
Q
After initial ED visit for sexual assault, what follow-up care should be offered to the patient? (4)
A
- Supportive counselling 2. HIV follow up and counselling with ID/HIV team in 3-5 days 3. Follow up gyne exam in 1-2 wks 4. Repeat serologic tests for syphilis and HIV in 6 wks, 3 mo and 6 mo
6
Q
ASA What are the features of ASA poisoning?
A
Vitals/Labs:
a. Fever & RR+ → respiratory alkalosis
CNS: Tinnitus (early) or hearing loss
Eyes/ Reflexes/ Mucous membranes - NAD
Skin: Diaphoresis
GIT:
a. Intestine: Nausea, vomiting, gastrointestinal bleed
b. Liver: Hepatoxicity (not renal failure)
Metabolic:
a. . metabolic acid base changes:
i) Phase 1, causes respiratory alkalosis (less common) and compensatory alkaluria (loose Na HCO3 and K from kidneys)
ii) Phase 2 paradoxic aciduria in presence of continued respiratory alkalosis
iii) Phase 3 anion gap metabolic acidosis → pulmonary/cerebral edema…(more common)
b .Hyperglycemia→ hypoglycemia
d. Hypokalemia
d. Hematology:
- low platelets & coagulopathy
- rhabdomyolysis
7
Q
ASA What is the Rx of ASA poisoning?
A
- Charcoal up to 6 hours (bezoar formation)
- 2.Glucose to all patients with altered mental status regardless of peripheral glucose blood level
- Treat hypokalemia
- Alkalinize serum to get urine pH between 7.5 - 7.6 to “trap” salicylate anions in blood and renal tubule..prevent it getting to CNS
- Hemodialysis: For CNS sx
8
Q
Causes of cardiogenic shock? (5) -signs/symptoms? -investigations? -treatment?
A
- Cardiomyopathy 2. Viral myocarditis 3. Post bypass 4. Coronary artery anomalies 5. Arrhythmias -signs and symptoms: cold shock, poor perfusion, heart failure -investigations: CXR, EKG, 4 limb BPs, ABG, lytes, lactate, echo -treatment: 1. Increase oxygen delivery (fluid and or lasix, afterload reduction, inotropic support with milrinone for ex) 2. Decrease oxygen demand (positive pressure ventilation, sedation, etc)
9
Q
Clinical features seen in minor electrical burns? -treatment?
A
Usually from biting an electrical cord 1. Localized burns to mouth 2. Hospital admission is not necessary since these are nonconductive injuries (do not extend beyond site of injury) 3. Treat with topical antibiotic cream until the patient can be seen by plastics
10
Q
Criteria for pediatric brain death?
A
- Established etiology capable of causing neurological injury in absence of reversible conditions 2. No confounders including: unresuscitated shock, hypothermia ( 60 mmHg AND rise > 20 mm Hg 6. Ancillary tests: ONLY do this if cannot perform an element of clinical NDD (angiography [CT-angio] or nuclear med, NO MORE EEG IS ALLOWED)
11
Q
Drowning What are the symptoms of water intoxication?
A
hyponatremia, seizures, hypothermia
various infectious diseases including otitis externa
12
Q
How can pupillary findings assist in the diagnosis of toxic ingestions? -miosis? (5) -mydriasis? (2) -nystagmus? (3)
A
Miosis:
- opioids 2. organophosphates 3. clonidine 4. barbiturates 5. ethanol
Mydriasis: 1. anticholinergics (atropine, antihistamines, TCAs) 2. sympathomimetics (amphetamines, caffeine, cocaine, LSD, nicotine)
Nystagmus: 1. Ketamine 2. Phenytoin 3. Barbiturates 4. PCP (think darting eyes)
13
Q
How do you calculate estimated blood volume?
A
80 ml/kg
14
Q
How do you decide whether to give fosphenytoin or phenobarbital first?
A
Based on age! -fosphenytoin for > 1 yo -phenobarbital < 1 yo
15
Q
How do you estimate a patient’s weight based on age?
A
(Age x 2) + 9
16
Q
How do you estimate ETT size?
A
(Age/4) + 4
17
Q
How do you reverse rocuronium?
A
Sugammadex
18
Q
How does the viscosity of a hydrocarbon determine risk of aspiration pneumonitis?
A
The LESS viscous, the MORE chance of aspiration pneumonia (think that if it’s thin, it can spread out more in the lungs to cover larger surface area) -ie. gasoline, lamp oil, kerosene
19
Q
How to treat seizures secondary to toxic ingestion?
A
Use benzos ONLY! Do not use phenytoin since this may worsen Na channel blockade (most drugs cause Na blockade)
20
Q
In a TCA overdose, what is a predictor of toxicity?
A
Widened QRS –> get ECG asap: if widened, this is predictive of seizures and ventricular dysrhythmias -nothing else is predictive besides QRS (not drug level, not symptoms)
21
Q
In abdominal trauma, in general terms, which structures are more likely to be injured in a crush injury?
A
Midline structures since they are compressed against the spine
22
Q
Indications for dialysis? (5)
A
AEIOU -Acidosis -Electrolyte imbalance (hyperkalemia) -Ingestion -Overload (fluid) -Uremia
23
Q
Indications for intubation? (4 main categories)
A
- CNS: cannot protect airway (GCS < 8, no airway reflexes), loss of control of breathing 2. Resp: upper airway obstruction, hypoxemia, hypercapnea, severe WOB despite max medical tx 3. CVS: hemodynamic instability, to decreased metabolic demand 4. Logitistics: transport, procedures
24
Q
Indications for laparotomy in abdo trauma?
A
- Persistent hemodynamic instability with evidence of abdo injury 2. Penetrating injury to abdo 3. Pneumoperitoneum 4. Multisystem trauma and they need other OR procedures if evidence of abdo injury
25
Is activated charcoal recommended for use in poisonings? -how does it work? -when should it be given? -contraindications? (10)
YES!!! Thought to be potentially the most useful -activated by heat and creates network of pores that have large absorptive area, thus adsorbing toxins onto its surface and preventing absorption from GI tract -should be given within 1 hr of ingestion!!!!! -can cause vomiting
Contraindications: **CHEMICAL**
CamP Cyanide
Hydrocarbons
Ethanol
Metals
Iron
Caustics
Airway unprotected
Lithium Camphor Potassium
26
Is gastric lavage recommended for use in ingestions?
NO LONGER RECOMMENDED! -involves tube placement into stomach to aspirate contents followed by flushing with fluids -there is no objective data to support efficacy! -also it is time consuming and can induce bradycardia via vagal response and can delay definitive treatment (activated charcoal)
27
Is GCS a good prognostic indicator for drowning? -how long should you monitor GCS for?
GCS equal to or \> 6 generally means good prognosis and \< 5 bad prognosis...HOWEVER this is unreliable! -monitor GCS x 24-72 hrs before making a decision about withdrawal
28
Is syrup of ipecac recommended for use in ingestions?
NO! = no longer recommended for use given all the risks (cardiac toxicity, aspiration risk with vomiting)
29
Up to what age should a skeletal survey be ordered?
Up to age of 2 years (yield is lower after that)
30
What 3 medications can kill with one pill?
1. Oral hypoglycemics 2. TCAs 3. Calcium channel blockers
31
What 4 infections are diagnostic for sexual abuse in a non-sexually active child?
1. HIV 2. Syphilis 3. Gonorrhea 4. Chlamydia (other infections such as trichomonas, condyloma acuminata, herpes, BV is less clear)
32
What 4 organs are commonly injured in bike handlebar injury?
1. Liver 2. Spleen 3. Pancreas 4. Duodenal injury
33
What are 2 commonly used insecticides? -how do they differ in action and clinical features? -antidotes?
1. Organophosphates -bind irreversibly to acetylcholinesterase if left untreated and permanently inactivates the enzyme (known as AGING) -takes weeks to months to regenerate inactivated enzymes 2. Carbamates -form temporary bond only, allows reactivation of acetylcholinesterase within 24 hrs Antidotes: 1. Atropine (competitive antagonist of muscarinic receptors) 2. Pralidoxime (reverses binding of organophosphate to acetylcholinesterase) -not needed in carbamate poisoning since the bond degrades spontaneously
34
What are 3 components of stroke volume?
1. Preload 2. Afterload 3. Contractility
35
What are 3 side effects of anthracyclines?
1. Cardiomyopathy 2. Red urine 3. Myelosuppression
36
What are 3 things that increase risk of mortality in TBI?
1. Hypoxia 2. Hypo or hypercarbia 3. Hypotension
37
What are 3 things you can tell the team to ensure good quality CPR?
1. Compress 1/3 of AP diameter of chest 2. Aim for 100 compressions/min 3. Allow complete recoil 4. Minimize interruptions 5. No leaning (stool if needed) 6. Change CPR providers q2min
38
What are 3 types of electrical burns?
1. Minor electrical burns (ie. result of biting an extension cord) 2. High-tension electrical wire burn 3. Lightning burn
39
What are 4 contraindications to the use of an IO?
1. Placement in fractured bone 2. Placement through dirty or infected skin 3. Use in patients with bone disorders (osteopetrosis or osteogenesis imperfecta) 4. Repeat attempt into the same bone
40
What are advantages of ketamine over other sedatives? -side effects?
1. Maintains upper airway muscle tone and does not cause resp depression (maintains spontaneous breathing) 2. Does NOT cause hypotension = causes endogenous catecholamine release so maintain blood pressure and heart rate 3. Provides sedation, analgesia, amnesia all at once 4. Rapid onset and short duration of action Side effects: 1. Increased secretions 2. Post-sedative vomiting 3. Hypertension 4. Unpleasant hallucinations 5. Laryngospasm (rare)
41
What are anatomical considerations in pediatric patients that influence effect of abdominal trauma? (4)
1. Less fat and muscle for protection 2. Flexible ribs = less likely to fracture but underlying structures can still be injured 3. Multiple injuries more common since organs are in close proximity 4. Increased risk for gastric distention (aspiration risk, can be mistaken for abdo distension as result of trauma)
42
What are clinical features of high-tension electrical wire burns? -treatment?
Clinical features: 1. Deep muscle injury that cannot be readily assessed initially from high voltage = look for points of entry of current through the skin and exit site (usually current enters through upper extremity with exit through lower extremity onto the ground and injuries any organ or tissue in its path) 2. Cardiac abnormalities: arrythmias, asystole 3. Resp: resp arrest, aspiration 4. Renal: acute renal failure from rhabdomyolysis and myoglobinuria 5. Neurologic: motor paralysis, loss of consciousness 6. Abdominal: viscus perforation and solid organ damage 7. MSK: compartment syndrome from deep burns Treatment goals: supportive basically with focus on AGGRESSIVE hydration in order to wash out the kidneys, ALWAYS admit for observation given you don't know the extent of the injury, early debridement of wounds, tetanus prophylaxis
43
What are clinical features of osteogenesis imperfecta? (5)
1. Blue sclera 2. Wormian bones (extra bones in between sutures) 3. Dentinogenesis imperfecta (poorly developed, discolored teeth) 4. Hearing loss 5. And of course, frequent fractures with little force
44
What are contraindications to a foley catheter in a trauma? (4)
1. Blood at the urethral meatus 2. Pelvis injury (high risk for associated GU injury) 3. Rectal injury 4. High riding prostate
45
What are contraindications to CT scan in a trauma patient?
UNSTABLE or indication for emergent OR -CT should NOT be used for screening; should be used for characterizing and staging of suspected injuries
46
What are ECG findings in a patient with hypothermia?
1. J wave (pathognomonic) = after R wave, see a rounded bump (kind of like RSR' but rounded contour) 2. PR, QRS, QT elongation
47
What are indications for laparotomy in abdominal trauma? (4)
1. Hemodynamically unstable patient with positive FAST or DPL 2. Free air on AXR 3. Peritonitis 4. Positive CT scan
48
What are key questions to ask on history for a patient coming in with an animal bite?
1. Circumstances surrounding the bite -type of animal (domestic or wild) -provoked or unprovoked -immunization status of child (tetanus) and animal (rabies)
49
What are methods of GI decontamination after ingestions? (4) -Which two are the only ones likely to have significant clinical benefit in management of poisoned patient?
1. Activated charcoal 2. Whole bowel irrigation (THESE ARE THE ONLY TWO THAT ARE RECOMMENDED FOR USE) 3. Gastric lavage 4. Syrup of ipecac to induce vomiting
50
What are possible complications of IOs? (4)
1. Extravasation of fluid 2. Superficial skin infection 3. Osteomyelitis (rare) 4. Theoretical risk for bone growth arrest, fat embolism but these have not been reported
51
What are possible internal complications from lightning burns? (3)
1. Cardiac arrest (asystole, PVCs, VF, MI) 2. CNS: cerebral edema, hemorrhage, seizures 3. Renal: rhabdomyolysis and renal failure
52
What are predictors for good outcome in pediatric cardiac arrest? (6)
1. Initiation of prompt CPR 2. Witnessed event 3. Out of hospital arrest 4. Short interval to EMS 5. Short duration of CPR 6. Initial rhythm of VT or VF
53
What are rewarming methods for hypothermic child? -temp 32-35 (mild) -temp \<32
Temp 32-35 (mild hypothermia): passive rewarming by removing cold clothing, placing the patient in a warm, dry environment with blankets Temp \< 32: active rewarming with overhead heaters, heating blankets, gastric/colonic irrigation with warm fluids, peritoneal dialysis, pleural lavage, ECMO, warmed humidified oxygen by face mask or ETT
54
What are risk factors for airway involvement in burns?
1. Closed space 2. Any respiratory distress 3. Singed hairs 4. Soot around face 5. Burns involving steam/combustibles, etc 6. Carbanaceous sputum
55
What are risk factors for infection after an animal bite? (7)
1. Immunocompromised patient 2. Crush or deep puncture wounds 3. Delay in treatment \> 24 hrs 4. Human and cat bites 5. Bites on hand, foot, genitals 6. Perforation of bone or tendons 7. Presence of foreign material
56
What are side effects of ketamine? (6)
1. Hypertension 2. Tachycardia 3. Amnesia 4. Analgesia 5. Bronchorrhea 6. Bronchodilation \*\*\*causes endogenous release of catecholamines -great for kids who are hemodynamically unstable
57
What are side effects of lasix? (4)
1. Hyponatremia 2. Hypokalemia 3. Nephrocalcinosis 4. Metabolic alkalosis
58
What are side effects of propofol? (3) -contraindications?
Side effects: 1. Hypotension 2. Hypoventilation 3. Propofol-related infusion syndrome Contraindications: 1. Hemodynamically unstable patient 2. Children with egg/soy allergies
59
What are side effects of risperidone? (7)
1. Acute dystonic reaction 2. Neuroleptic malignant syndrome 3. Diabetes 4. Weight gain 5. Seizures 6. Hepatotoxicity 7. Prolonged QT
60
What are signs of neurogenic shock?
Spinal cord injury at level of sympathetic chain (T1 to L2) -loss of sympathetic output to heart, vessels, etc. -signs: inappropriately normal HR in hypotension
61
What are signs of salicylate overdose? Treatment?
Tinnitus is often 1st symptom GI upset (vomiting), confusion/cerebral edema, impaired plt function, pulmonary edema, central hyperventilation (tachypnea) (Causes uncoupling of oxidative phosphorylation) -give bicarb for urine alkalination -call nephro (may need dialysis) -need to order salicylate levels q2h until they peak and then document at least 2 decreasing ones
62
What are the 2 divisions of the lung?
Conducting zone = rigid passageways from oropharynx to terminal bronchioles = physiologic dead space -respiratory zone = from respiratory bronchioles and alveoli = sites of gas exchange
63
What are the 3 causes of hypercapnea?
1. Hypoventilation (eg. CCHS, drugs) 2. Obstructive lung disease (eg. asthma, OSA) 3. Neuromuscular disease (low tidal volumes)
64
What are the 3 components of abdominal compartment syndrome?
1. Hypotension (from IVC compression) 2. Respiratory distress (from increased intraabdominal pressure) 3. Decreased urine output (from bladder compression and from hypotension)
65
What are the 3 most commonly injured organs in abdominal blunt trauma?
1. Spleen 2. Liver 3. Bowel
66
What are the 4 contraindications to rapid sequence intubation?
1. Anticipated difficult airway and unsuccessful attempt 2. Significant facial or laryngeal trauma 3. Upper airway obstruction 4. Cardiopulmonary arrest
67
What are the 4 stages of iron toxicity?
1. Initial stage: 30 min - 6 hr post ingestion -profuse vomiting and bloody diarrhea -volume losses 2. Second stage: 6-24 hrs post -quiescent phase, GI symptoms resolve 3. 3rd stage: 12-24 hrs post -multisystem organ failure, shock, hepatic and cardiac dysfunction, ARDS, metabolic acidosis -death occurs most cmomonly during this stage 4. 4th stage: 4-6 wks post -GI strictures and obstruction
68
What are the 4 types of shock? -lab markers of perfusion? (3)
1. Distributive (sepsis, anaphylaxis) 2. Cardiogenic 3. Neurogenic 4. Hypovolemic Lab markers of perfusion 1. lactate 2. Mixed venous sat 3. Gas
69
What are the 5Cs of intubation confirmation?
1. Clinical by auscultation 2. Clinical by direct laryngoscopy 3. CO2 detected 4. CXR 5. Condensation in the ETT
70
What are the 6 Hs and 4 Ts?
1. Hydrogen ion 2. Hypoglycemia 3. Hypovolemia 4. Hyper/hypokalemia 5. Hypothermia 6. Hypoxemia 1. Toxins 2. Tension pneumothorax 3. Tamponade 4. Thromboembolism
71
What are the 7 Ps of intubation?
1. Prepare (patient/physician/pharmacology/proper set of equipment) 2. Preoxygenate 3. Premedicate (include atropine if \< 1 yo) 4. Paralysis 5. Pressure on cricoid cartilage (only if RSI) 6. Placement of ETT (4 + age/4, depth = ETT size x 3) 7. Post intubation care
72
What are the actions of atropine in rapid sequence intubation? (2)
1. Minimizes vagal stimulation (prevents bradycardia) 2. Decreases oral secretions
73
What are the adverse effects of succinylcholine and subsequent relative contraindications?
1. Hyperkalemia --\> do not use in renal failure 2. Increased intraocular pressure --\> do not use in patients with open globe injury 3. Malignant hyperthermia 4. Rhabdomyolysis and myoglobinuria --\> do not use in trauma or burns \> 48 hrs after injury 5. Neuromuscular disease
74
What are the antidotes for the following: -acetaminophen -anticholinergics -benzos -beta-blockers -calcium channel blockers -ethylene glycol/methanol -iron -methemoglobinemia -organophosphates -salicylates -sulfonylureas -TCAs
-acetaminophen: N-acetylcysteine -anticholinergics: neostigmine or physostigmine -benzos: flumazenil -beta blockers: glucagon -calcium channel blockers: insulin and calcium salts -ethylene glycol/methanol -iron: deferoxamine -methemoglobinemia: methylene blue -organophosphates: atropine & pralidoxime -salicylates: sodium bicarb -sulfonylureas: octreotide -TCAs: sodium bicarb
75
What are the biggest concerns with use of etomidate in rapid sequence intubation for critically ill patients? (2)
1. Adrenal suppression 2. Hypotension \*\*\*Most studies show there is little evidence to support this though
76
What are the changes in your lungs during air transport? (2)
1. Decreased pressure and thus increased gas expansion 2. Decreased PaO2
77
What are the characteristics of warm shock vs. cold shock?
Warm shock: -vasodilators \> vasoconstrictors -warm, flash cap refill, wide pulse pressure, bounding pulses -shock because of low preload and loss of autoregulation Cold shock: -vasoconstrictors \> vasodilators -cold, poor pulses, prolonged cap refill, narrow pulse pressure -shock because of myocardial depression + increased afterload (possible effect of endotoxin on myocardium)
78
What are the clinical features of foxglove or lily of the valley poisoning?
CARDIAC effects! = nausea, vomiting, bradycardia, AV block, hyperkalemia
79
What are the clinical features of increased ICP in an infant?
1. Sunsetting sign 2. Shrill cry 3. Irritability 4. Bulging AF
80
What are the clinical features of iron toxicity? -toxic dose?
Think GI symptoms! Iron is directly corrosive to the GI mucosa: 1. GI bleed from ulceration and perforation--\> hematemesis, melena 2. Hypotension: due to massive volume losses from increased permeability of capillaries 3. Accumulation of iron in liver and heart = liver toxicity, cardiac dysfunction 4. Anion gap metabolic acidosis due to hypotension and hypovolemia -toxic dose: \> 40 mg/kg
81
What are the clinical features of lower abdominal lap belt injuries? (3)
1. Bladder rupture 2. Chance fracture: L1 & L2 3. Bowel rupture
82
What are the clinical features of organophosphate toxicity? -pathophysiology? -treatment and 2 antidotes?
Think DUMBBELS (tells you effects at muscarinic receptors) Diarrhea Urination Miosis Bradycardia Bronchospasm/bronchorrhea Emesis Lacrimation Salivation -at nicotinic receptors: muscle weakness, fasciculations and eventually paralysis, delirium =these are all cholinergic symptoms (ie. the opposite of anticholinergic signs) Pathophysiology: -organophosphates bind to and inhibit the action of acetylcholinesterase THUS nothing to break down acetylcholine at the NMJ (muscarinic receptors) so you can a lot of parasympathetic activation Treatment: 1. Basic decontamination = washing all exposed skin with soap and water and immediately removing all exposed clothing 2. Supportive care with intubation if decreased LOC/risk of aspiration Antidotes for treatment: 1. Atropine boluses or continuous infusion = competitive antagonist for muscarinic receptors so less acetylcholine can bind to the receptors; target to resolve respiratory secretions -controversial whether you should give activated charcoal if ingested insecticides 2. Pralidoxime: breaks the bond between the organophosphate and the enzyme reactivating acetylchoinesterase (only effective if used before bond ages and becomes permanent)
83
What are the clinical features of serotonin syndrome?
SHIVERS 1. Shivering 2. Hyperreflexia 3. Increased temperature (hyperthermia) 4. Vitals: increased HR, RR, labile BP 5. Encephalopathy (agitation, delirium, confusion) 6. Restlessness 7. Sweating
84
What are the clinical features of TCA overdose? (think triad)
Overall blocks Na channels and inhibition of GABA reuptake 1. CNS: -seizures 2. CVS -prolonged PR/QRS/QT -arrhythmias -hypotension -LOOK at AVR = positive R' wave in AVR 3. Anticholinergic -hot as hell (hyperthermia has very bad prognostic effect) -blind as bat -mad as hatter -red as beet -dry as bone -bowel and bladder lose their tone
85
What are the definitions of: -SIRS -Sepsis -Severe sepsis -Septic shock
SIRS: 2+ hyper/hypothermia, increased heart rate and/or RR, low or high WBC -sepsis = SIRS + presumed infection -severe sepsis = sepsis + organ dysfunction -septic shock = sepsis + refractory hypotension
86
What are the effects of epinephrine in shock? -low dose -high dose
Epinephrine: -low dose: decreases alpha 1, increases beta 1, beta 2, decreases SVR (reduces vasoconstriction) -high dose: alpha 1, beta 1, beta 2, increases SVR
87
What are the effects of the following when used in rapid sequence intubation: -Fentanyl -Midazolam -thiopental -etomidate -ketamine -propofol
1. Fentanyl: sedation, analgesia -little hemodynamic effect 2. Midazolam: sedation, amnesia, NO ANALGESIA EFFECT -respiratory and hemodynamic depression 3. Thiopental: sedation with NO ANALGESIA -respiratory and hemodynamic depression -laryngospasm and bronchospasm -reduces ICP 4. Etomidate: sedation with NO ANALGESIA -minimal respiratory and hemodynamic depression -decreases cerebral blood flow, metabolic rate and ICP -suppresses cortisol production and may produce myoclonus -do NOT use in sepsis! 5. Ketamine: dissociative sedation, amnesia AND analgesia! -minimal hemodynamic effects -bronchodilation -may cause laryngospasm -increases oral secretions -no longer thought to increase ICP (multiple studies) 6. Propofol: sedation, rapid onset and offset -hypotension
88
What are the equations for oxygenation and ventilation?
Oxygenation: PaO2 = [(Atm - humidity) x FiO2] - (CO2/0.8) ie. [(760-47) x 0.21] - (CO2/0.8) -ventilation: RR x TV (this is minute ventilation)
89
What are the general management principles for a hemodynamically stable patient with: 1. Lower penetrating chest wounds 2. Anterior penetrating abdominal wounds
1. Lower penetrating chest wound: serial chest exams, thoracoscopy, laparoscopy, CT scan to look for diaphragm injury 2. Anterior penetrating abdo wound: FAST, wound exploration, DPL, serial exams, laparoscopy \*\*\*\*remember not to miss diaphragmatic injuries = commonly missed and never heal on their own leading to diaphragmatic herniation
90
What are the good prognostic indicators of drowning? (4)
1. ROSC \< 10 minutes 2. Submersion \< 5 minutes 3. PERL at scene 4. NSR at scene
91
What are the indications for abdo CT in trauma patients? (7)
1. Seat belt sign 2. Hx or mechanism suggestive or distracting injuries 3. AST \> 200 or ALT \> 125 4. Gross or microhematuria \> 50 RBCs 5. Decreasing HCT or \<30% 6. Unaccountable fluid or blood requirements 7. Inability to perform serial exams or appropriately examine the abdomen Ultrasound is NOT sufficient in setting of trauma; CT is much better for visualizing solid organ injuries
92
What are the indications for antibiotic therapy in a patient presenting with a bite? (7) -oral vs. IV? -first choice for abx coverage?
1. Moderate or severe bite wounds (especially if edema or crush injury present) 2. Puncture wounds (especially if penetration of bone, tendon or joint) 3. Facial bites 4. Hand and foot bites 5. Genital area bites 6. Wounds in immunocompromised 7. Wounds with signs of infection 8. All human and cat bites (dog = controversial) \*\*\*Oral vs. IV depends on the wound, signs of infection, and immune status 1st line: PO amoxi-clav for empirical therapy or IV ampicillin/sulbactam (do NOT use first gen cephalosporins since they don't have good coverage for oral microbes) -if pen allergic: azithromycin
93
What are the indications for imaging prior to LP?
1. Papilledema 2. Focal neuro signs 3. Decreased LOC or coma
94
What are the indications for use of atropine as premedication in rapid sequence intubation? (3)
1. Infants \< 1 yo 2. Children \< 5 yo if using succinylcholine 3. Patients receiving 2nd dose of succinylcholine
95
What are the key distinguishing clinical features of ingestion of the following: -ethanol (triad) -methanol -isopropyl alcohol -ethylene glycol
-Ethanol triad: hypoglycemia, hypothermia, coma -methanol: severe metabolic acidosis and permanent retinal damage leading to blindness (due to formic acid formation = blocks mitochondria, thus metabolic acidosis) -isopropyl alcohol: gastritis, hyperglycemia, hypotension -ethylene glycol: severe metabolic acidosis, cranial nerve palsies and cause renal damage by precipitation of calcium oxalate crystals
96
What are the main differences between adult and pediatric airway? (5)
For pediatric airway: 1. Large head and occiput 2. Large, floppy epiglottis 3. Larynx is more anterior 4. Cricoid is narrowest portion of airway 5. Small oropharynx with large tongue
97
What are the main differences in NDD in adults vs. children?
1. Children \> 1 yo = same as in adulst (2 people can do the exam at the same time) 2. Children \> 30 d and \< 1 yo = 2 separate exams separated by time interval (interval not specified) 3. Children \< 30 d: minimum time from birth 48 hrs, 2 exams separated by at least 24 hrs
98
What are the management steps in TBI?
Avoid:
1. Hypoglycemia
2. Seizures
\*\*Treat elevated ICP + impending herniation with hyperosmolar therapy
1. Elevate head of **bed** - 30 degrees & **head midline**
**2. Vitals:**
**a.** Temp (no hyperthermia, do not cool-goal 36.5-37.5°C)
b. BP (\>5th percentile)
3. **Resp**:
a. Maintain normocarbia (35-40 mmHg)
b. Prevent hypoxia (pO2 \> 60 mmHg)
4. Ensure adequate **sedation and analgesia**
99
What are the points in GCS?
EVM!!!! Eyes: 1 - no eye opening 2 - eye opening to painful stimuli 3 - eye opening to verbal stimuli 4 - spontaneous eye opening Verbal: 1 - none 2 -incomprehensible sounds 3 - incoherent words 4 - disoriented conversation 5 - normal conversation Motor: 1 - None 2 - decerebrate posturing (extension) 3 - decorticate posturing (flexion) 4 - withdrawal to pain 5 - localizes pain 6 - follows commands/normal
100
What are the reversal agents for the following: -benzos -non-depolarizing muscle blocking agents (ie. rocuronium) -depolarizing muscle blocking agents (ie. succinylcholine)
-Benzos: flumazenil (gaba receptor antagonist) -rocuronium: neostigmine (acetylcholinesterase inhibitor) -succinylcholine: no reversal agent, just TIME
101
What are the most important steps in sepsis guidelines that affects mortality? (3)
1. Need 20 cc/kg NS bolus within first 10 minutes 2. Need 60 cc/kg NS bolus within first 60 minutes 3. Need antibiotics in within first 60 minutes
102
What are the settings on a ventilator? (5) -what changes can you make on the ventilator to fix low sats vs. high CO2?
1. Timing: synchronized, assist control, prsesure support 2. Modes: pressure vs. volume 3. Rate 4. PEEP 5. I/E Trouble shooting: 1. Low sats: DOPE, increase FiO2 or PEEP (increases surface area available for gas exchange in order to help oxygenation) 2. High CO2: increase minute ventilation with increased tidal volume (PIP) or RR
103
What are the side effects of midazolam? (3)
1. Mild hypotension 2. Resp depression (especially when used with opioids) 3. Paradoxical reaction in 20% of kids
104
What are the side effects of NSAID use in neonates? (ie. treatment of PDA)?
1. Transient increase in GFR 2. Platelet dysfunction 3. Increased NEC (slight mesenteric vasoconstrictor = decreased blood flow to gut) 4. Hypoglycemia
105
What are the special considerations in RSI?
1. Preoxygenate prior to BMV in order to minimize positive pressure as may distend stomach 2. Deep sedation and paralysis to increase chances of success 3. Cricoid pressure to compress esophagus during laryngoscopy (controversial)
106
What are the steps of RSI?
AMPLE Preparation: SOAP-ME (suction, oxygen, airway assessment & equipment, position, medications, environment) Preoxygenation Premedication Sedation Sellick Maneuver Paralysis Intubation & confirmation
107
What are the steps to clearing C-spine on xray film?
1. Ensure adequacy of film -need to see C1-C7 and space between C7 and T1 on lateral film to qualify as adequate film -if cannot see space between C7 and T1, need swimmers view 2. Assess vertebral alignment -anterior vertebral line, posterior vertebral line, spinolaminar line, posterior spinal line 3. Assess bony integrity 4. Assess disc spaces 5. Odontoid view -look for disruptions in odontoid and atlas 6. Soft tissues -prevertebral soft tissue should be \< the width of the whole vertebrae from C5-C7 \*\*\*After clearance of films, do CLINICAL clearance: take off C collar and palpate for tenderness on spinous processes and ask patient to do neck ROM
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What are the toxic doses for: -acetaminophen -ibuprofen -ASA
Acetaminophen: 150 mg/kg Ibuprofen: 100 mg/kg ASA - 150 mg/kg
109
What are the underlying cause of Reye syndrome? -clinical features? (3) -what is ONE distinguishing feature that helps you differentiate between Reye syndrome vs. liver failure? -treatment?
Precipitated in a genetically susceptible person by the interaction of a viral infection (influenza and varicella) and ASA use = secondary mitochondrial hepatopathy Clinical features: overall, acute onset of vomiting and encephalopathy 1. Neurologic symptoms: can progress to seizures, coma and death 2. Liver dysfunction (coagulopathy, transaminitis, hyperammonemia) BUT NORMAL SERUM BILIRUBIN LEVELS (unlike in liver failure) 3. Increased intracranial pressure and resultant herniation = very important contributor to morbidity and mortality Treatment: no effective therapy except supportive care -may need liver transplant
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What are two coingestions you should ALWAYS check for in a patient with suspected ingestion?
Acetaminophen and salicylate
111
What arterial blood gas pattern is classic for salicylate poisoning?
Metabolic acidosis with respiratory alkalosis! -salicylates directly stimulate the medullary respiratory drive center causing tachypnea -also cause lactic acidosis due to uncoupling of oxidative phosphorylation
112
What baseline investigations will you order for an ingestion?
1. Glucose 2. Lytes 3. Renal Function 4. LFTs 5. EKG 6. Serum osmolality 7. Blood gas 8. Urine tox screen 9. Ethanol level 10. Other alcohol levels 11. Acetaminophen, salicylate level
113
What bloodwork should be ordered for a patient in a housefire?
1. CBC: look for signs of bleeding 2. Lytes: look for hyperkalemia 3. Renal function to rule out renal failure 4. BLOOD CARBOXYHEMOGLOBIN (HbCO = rule out carbon monoxide poisoning) 5. Gas 6. Urinalysis for myoglobin
114
What cardiac medication taken during pregnancy increases risk of hypothyroidism in baby?
Amiodarone = has a lot of iodide in it! -amiodide :)
115
What does your GCS have to be in order to qualify for brain death criteria?
GCS 3
116
What emergency drugs can be given through an ETT? (5)
LEAN-V 1. Lidocaine 2. Epinephrine 3. Atropine 4. Naloxone 5. Vasopressin \*\*Epi = 10x IV dose \*\*other meds = 2x IV dose -need to follow administration with a 5 ml NS flush and PPV to bag it in
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What fractures should raise suspicion of child abuse? (5)
1. Spiral fractures 2. Posterior rib fractures 3. Spinal fractures 4. Metaphyseal fractures 5. Femoral fractures in non mobile child 6. Scapular fractures
118
What ingestions are radioopaque on abdominal radiograph?
CHIPS 1. Chloral hydrate 2. Heavy metals (iron, lead, arsenic) 3. Iodides 4. Phenothiazines, psychotropics (TCAs) 5. Slow release capsules (enteric coated tablets)
119
What inotrope is used for: -cold shock? -warm shock?
Cold shock = dopamine or epinephrine Warm shock = norepinephrine
120
What is "sudden sniffing death?" -treatment?
Volatile hydrocarbons that are commonly abused by inhalation (ie. halogenated ones) can sensitize the myocardium to the effects of endogenous catecholamines = increased risk of Vtach and Vfib (usually refractory to conventional management) Treatment: still follow PALS algorithm but consider treatment with beta blocker to block effects of endogenous catecholamines on sensitized myocardium
121
What is a normal ICP?
\< 20 mm Hg
122
What is an alternative to neuromuscular blockade in RSI if contraindicated?
Propofol + Fentanyl may be just as effective in some studies
123
What is evidence for use of lidocaine as premedication in rapid sequence intubation?
Used in head injury and thought to reduce rise in ICP associated with laryngoscopy No evidence to support use in 2001 literature review (no improvement in neurological outcome)
124
What is oil of wintergreen?
A salicylate!!!
125
What is systemic vascular resistance in cold shock?
Increased!
126
What is TBI management stps in PICU? -what are indications for hyperventilation?
1. ICP probe if GCS \< 8 (only in trauma) 2. If ICP \> 20 x 5 mins, then: -give sedation -muscle relax -hyperosmolar therapy -drain EVD if present -elevate HOB \*\*Only hyperventilate (PCO2 25-30) if impending herniation (Cushing's triad, blown pupil) = this is the fastest way to decrease ICP in a herniating patient
127
What is the action of neostigmine?
Acetylcholinesterase inhibitor = thus increases acetylcholine action at the muscarinic receptors
128
What is the antidote for lead toxicity?
2,3-dimercaptosuccinic acid
129
What is the chance that the first benzo given will stop status epilepticus? -what about the 2nd benzo? -if EMS or parent has already given 1, do you include that as the 1st dose?
80% success rate for first benzo -20% for 2nd dose -if EMS or parent has already given 1, you include that as the 1st dose.
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What is the criteria for ARDS? (Berlin criteria) -causes? -treatment?
1. Within 1 week of known clinical insult (acute) 2. Bilateral lung opacities 3. Not explained by CHF or fluid overload \*\*mild = P/F 200-300, mod = 100-200, severe = \< 100; all require a PEEP of at least 5 -causes: sepsis, pneumonia, trauma, aspiration, TRALI, etc. -tx: lung protective ventilation (high PEEP, low tidal volumes to reduce barotrauma which worsens ARDS), early steroids, proning, ?NO (no evidence that it improves morbidity or mortality), ?surfactant (ditto)
131
What is the criteria for transfer to burn centre? (8)
1. Partial thickness and full thickness burns of greater than 10% BSA 2. Partial thickness and full thickness burns involving face, eyes, ears, hands, feet, genitalia, joints 3. Full thickness burns of any size in any age group 4. Significant electrical burns 5. Burns suspicious for abuse 6. Significant chemical burns 7. Inhalation injury 8. Burn injury in patients with preexisting illness that could complicate treatment
132
What is the definition of heat stroke vs. heat exhaustion?
Heat stroke: temp \> 40 with neurologic symptoms -heat exhaustion: T 38-40 without neurologic symptoms
133
What is the definition of status asthmaticus? -RFs for ICU admission? -ICU management?
Failure to respond to initial bronchildator therapy -RFs for ICU admission, prior ICU, h/o increased bronchodilator use with no improvement, asthma exacerbation despite recent steroids, frequent ED visits, sats \< 92% despite O2 -ICU management: MgSO4 --\> continuous nebs --\> IV ventolin (no evidence) --\> NIPPV --\> adjuncts (eg. ketamine, epi, aminophylline) --\> intubation
134
What is the dose for chloral hydrate? -possible side effects?
20-75 mg/kg/dose 60 minutes prior to procedure -side effects: possible resp depression, unreliable absorption, unreliable in children \> 3 yo
135
What is the dose of activated charcoal? -common side effects? (2)
1 g/kg in children and 50-100 g in adolescents and adults -common side effects: 1. vomiting (20%) 2. constipation
136
What is the indication for follow up xrays in foreign body ingestions?
Only if signs of obstruction or abdominal pain
137
What is the initial management of ALL animal bites? -what about hand bites?
1. If needed, obtain culture 2. Apply local anesthetic 3. Clean and vigorously irrigate with copious amounts of normal saline -no evidence for antibiotic containing solutions over saline and can actually cause local irritation 4. Debride devitalized tissue 5. MAY be able to do primary closure on facial bite wounds \< 6 hrs old BUT this is unclear....most bites should be delayed primary closure (3-5 d by plastics) vs. secondary intention \*\*\*\*Definition do NOT suture anything \> 24 hrs old \*\*\*Hand bites: all need to be immobilized until follow up assessment 3 days later
138
What is the management for shockable rhythm (ie. VT/VF)?
Shock as SOON as you can with 2J/kg --\> then CPR x 2 mins, then shock again at 4 J/kg if able + epi --\> CPR x 2 mins, recheck rhythm and pulse q2mins, epi q3-5mins -coordinate 15:2 if no advanced airway, no need to coordinate once intubated -epi dose = 0.01 mg/kg 1:10000 IV \*\*\*Remember that CPR is your first priority, THEN defibrillation, then epi is your last resort (don't have great evidence about whether it helps or not)
139
What is the management for TCA overdose? -how long should you monitor them for if asymptomatic?
Charcoal: give even if \> 1 hr since gastric emptying may be delayed (due to anticholinergic effect) If decreased LOC: intubate asap Bicarb: for QRS \> 100 msec, arrhythmias, hypotension, acidosis -NaHCO3 1-2 mEq/kg bolus, then start infusion Pressors: norepinephrine for hypotension always! Active cooling if hyperthermic Monitor x 6 hours
140
What is the management of a 13 yo who was just sexually assaulted?
1. History and physical, document findings 2. Report to CAS 3. Pregnancy test and emergency contraception 4. STI screen and prophylaxis 5. Forensic kit if \< 72 hrs
141
What is the management of burns?
1, Remove clothes and other exposures 2. ABCDEs (100% FiO2) + rapid trauma assessment ALWAYS (increased risk of having secondary trauma) 3. Wash burns with tepid water, flush chemical burns, cool minor burns with cool saline 4. Estimate %BSA involved with partial/full thickness 5. If \> 10%, then at risk for SIRS response and fluid resuscitate with: Parkland formula = 4 cc/kg/% BSA + maintenance crystalloid (1/2 in first 8 h, 1/2 in 16 h) -monitor urine output with foley
142
What is the management of carbon monoxide poisoning?
Think about this in the winter time!!! May have CO leak in house while heat is on. Whole family may present with flu like symptoms, delayed neuropsychiatric syndrome (can happen up to weeks after poisoning) 1. Order carboxyhemoglobin level on blood gas Treatment: 1. 100% oxygen until levels \<5% 2. If anemic, transfuse to Hgb 100 3. Hyperbaric oxygen for CNS symptoms, CVS symptoms, pregnancy
143
What is the management of iron toxicity?
1. Draw serum iron levels 4-6 hrs after ingestion along with gas, CBC, glucose, liver enzymes, LFTs 2. AXR to look for iron tablets 3. Monitor closely for hypotension with aggressive fluid support 4. Whole bowel irrigation!!!! (remember that activated charcoal does NOT absorb iron) 5. Deferoxamine for moderate to severe iron intoxication -IV infusion at 15 mg/kg/hr until urine runs clear (deferoxamine iron complex colors urine red)
144
What is the most common arrthythmia associated with halogenated hydrocarbon abuse?
VT and VF
145
What is the most common bacterial etiology of spontaneous bacterial peritonitis?
Strep pneumo!!!
146
What is the most common physical finding in sexual abuse?
Normal examination
147
What is the most important complication of hydrocarbon toxicity? -baseline investigations (2)?
Aspiration pneumonitis due to inactivation of type II pneumocytes and resulting surfactant deficiency (aspiration occurs during coughing and gagging at time of ingestion or vomiting after ingestion) -baseline investigation: blood gas and CXR, monitor for 6 hours
148
What is the onset and half life of: -succinylcholine -rocuronium
Succinylcholine: -onset 15-30 secs -duration: 5-15 minutes Rocuronium: -onset 30-60 secs -duration: 30-45 mins
149
What is the progression of acetaminophen overdose?
0-24 hrs: GI irritation or asymptomatic 24-48 hrs: liver involvement, increased PTT is the earliest marker, than rise in AST 72-96 hrs: fulminant hepatic failure, renal failure 4-14 days: recovery or death
150
What is the treatment for cyanide toxicity?
1. 100% oxygen 2. You have two options: a) Cyanide antidote kit: -sodium nitrite (produces methemoglobin which then reacts with cyanide to form cyanmethemoglobin) -sodium thiosulfate (increases metabolism of cyanmethemoglobin to hemoglobin and less toxic thiocyanate) b) Hydroxocobalamin (vitamin B12) (reacts with cyanide to form nontoxic cyanocobalamin which is then excreted in urine) = superior to cyanide antidote kit so is now the preferred antidote
151
What is the treatment for isopropyl alcohol ingestion?
Supportive care
152
What is the treatment for methanol overdose? (2)
1. Fomepizole 2. Folate
153
What is the treatment for opiate overdose?
1. MAINLY SUPPORTIVE!!!! 2. Naloxone only if respiratory depression -remember that different opiates have different half lives (ie. methadone lasts \>\> morphine \>\> fentanyl)
154
What is the treatment for ventricular tachycardia? -stable? -unstable?
-Stable: call cardio and may start amio, lidocaine, etc. -Unstable = refer to pulseless arrest (shock + CPR)
155
What is the treatment of hydrocarbon ingestion? -main complication of hydrocarbon ingestion? -main complication of hydrocarbon inhalation?
Observation and supportive care for respiratory symptoms!!! -emesis and lavage are CONTRAINDICATED given the risk of aspiration -activated charcoal is NOT useful because it does not bind the common hydrocarbons and can also induce vomiting -main complication of ingestion: 1. ARDS (some require intubation and ECMO) from aspiration pneumonitis -main complication of inhalation: 1. Arrhythmias and cardiac arrest
156
What is Waddell's triad?
Pattern of injury when a child is struck by a car while crossing the street 1. Fractured femur (impact from car) 2. Head injury (thrown a distance and hit their head on ground) 3. Intra-abdominal or intra-thoracic injury (thrown a distance)
157
What is water intoxication?
Swallowing lots of water and thus getting hyponatremia and secondary seizures -can see in babies who go swimming and swallow a lot of water
158
What is whole bowel irrigation? -what are the usual indications? (3)
Whole bowel irrigation: instill large volumes through NG tube (35 ml/kg/hr in children or 1-2 L/hr in adolescents) of GoLYTELY to cleanse the entire GI tract until rectal effluent runs clear -indications: 1. For slowly absorbed substances (sustained release preparations) 2. Substances not well absorbed by charcoal 3. Drug packets (ie. heroin or cocaine)
159
What is your arterial O2 content delivery?
(Hb x 1.34 x sats) + )PaO2 x 0.003)
160
What is your oxygen delivery equation?
Oxygen delivery = cardiac output x arterial O2 content
161
What lacerations should not be sutured? (4)
1. Puncture wounds 2. Mucosal surface lacerations (mouth, vagina) 3. Contaminated wounds that cannot be reliably cleaned 4. Human bites \*\*\*\*Some authorities recommend that wounds \> 12 hrs on arms and legs and \> 24 hrs on face should not be sutured and left to heal by secondary intention
162
What medication choices for RSI are appropriate for a patient in status epilepticus?
Propofol - anti-epileptic properties Succinylcholine - short acting (caution with rocuronium as you may not be able to tell if they're still seizing or not)
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What medication choices for RSI would be appropriate for an infant with tracheomalacia, croup, severe stridor, previous difficult intubation?
Do NOT paralyze! Propofol 3 mg/kg (rapid onset and offset) and topical lidocaine sprayed on the vocal cords -this will allow you to bag -will wear off quickly if difficult intubation
164
What organ systems are affected in patients suffering from heat stroke?
1. CNS: confusion, seizures, LOC 2. Cardiac: hypotension due to hypovolemia and peripheral vasodilation, myocardial dysfunction 3. Renal: ATN and renal failure from hypoperfusion 4. Hepatocellular injury 5. Heme: abnormal hemostasis (DIC usually) 6. Muscle: rhabdomyolysis from high temp
165
What personnel can perform neurological determination of death?
Any licensed physician with the requisite knowledge and skill -should be done by 2 physicians
166
What temperature should you rewarm to in resuscitation of a hypothermic patient?
34 degrees
167
What toxidrome does gravol cause?
Anticholinergic
168
What two ingestions are treated with urinary alkalinization with sodium bicarb?
1. TCA overdose 2. Salicylate overdose
169
When should you consider ordering an xray in a patient presenting with an animal bite? (2)
1. Penetrating injury over bone or joint for suspected fracture 2. Foreign body inoculation
170
When would you consider an epinephrine infusion in anaphylaxis?
After 3 doses of epi IM needed
171
Which 4 organs are most commonly injured with blunt abdo trauma?
1. Liver 2. Spleen 3. Kidneys 4. Pancreas OCCASIONALLY bowel (seatbelt injuries, handlebars)
172
Which animal bites are most likely to become infected? (2) -which should be cultured? (cat? human? dog?)
1. Human bites (regardless of mechanism of injury, ie. bite vs. closed fist against tooth) = high risk of infection, especially anaerobes 2. Cat bites = at least 50% even if early medical attention is received Thus need to culture ALL cat and human bites! -culture dog bite IF deep and extensive, \> 8 hrs old, early signs of infection, or immunosuppresed patient
173
Which animal bites require operative debridement and exploration? (3)
1. Cranial bites by large animal 2. Closed fist injury (involvement of metacarpophalangeal joint aka knuckle) 3. extensive wounds with a lot of devitalized tissue
174
Which microorganisms are associated with bites: -dog? -cat
Dog: staph, strep, pasteurella, capnocytophaga, anaerobes Cat: pasteurella (higher carriage in cats than dogs), staph, strep
175
Which patients require tetanus after an animal bite?
ALL patients who are incompletely immunized or if it's been longer than 10 years since last immunization -tetanus immunization schedule: 2, 4, 6, 18 mo, 4 yo and q10 years after that
176
Which structures are commonly injured with pelvic fractures? (3)
1. Urethra 2. Bladder 3. Rectum \*\*\*ALWAYS do a GU/rectal/vaginal exam in these patients
177
Why are alkali burns worse than acid burns in the eye?
Alkali = causes liquefactive necrosis (eats through tissue leaving more extensive injury) whereas acid = coagulation necrosis (buffered by tissue and limited penetration)
178
Why do we need O2? (on a biochemical level)
Glycolysis = 2 ATP + pyruvate -then pyruvate can either combine with O2 in Kreb's cycle to make 32 ATP OR -pyruvate can under anaerobic metabolism and create lactate and only 2 ATP -lactate = acidotic, cells don't like acidosis and thus they stop working and they die
179
Why do we NEVER use propofol infusions in peds for \> 12 hrs?
Propofol infusion syndrome = fatal!!!! -use of propofol sedation over several hours to days in children \< 12 yo is associated with hemodynamic collapse, metabolic acidosis, cardiac failure, profound shock and death
180
Why does ketamine have minimal effect on blood pressure?
Causes catecholamine surge to maintain blood pressure -however, in children who are catecholamine deplete (severe sepsis), may still get hypotensive with ketamine since there are no catecholamines left
181
Work-up for trauma patient?
CBC, coags, lytes, type and screen, LFTs, renal function, amylase, lipase, urinalysis for gross hematuria, consider serum ethanol/toxins, urine tox screen, CXR, C-spine, pelvic views, FAST, consider CT scan
182
B Blocker What are the features of toxicity
hypotension,
bradycardia and
hypoglycemia
183
184
Anticholinergic What are the signs of the Anticholinergic toxidrome?
* Blind as a bat, mad as a hatter, red as a beet, hot as Hades, dry as a bone.
* **Vitals**– Tachy, High RR, Hot
* **CNS**– agitated
* **Eyes**– mydriatic
* **Reflexes**– brisk
**•Skin/mucous**– Very dry skin, dry mouth
**•GI/GUT–** quiet bowel sounds, urinary retention
185
TCA What are the signs of the TCA overodose toxidrome?
* Vitals– Tachy, High RR, Hot, low BP
* ECG: wide QRS (\>100ms), arrythmia
* CNS–sedation, coma, seizures (notagitated)
* Eyes– mydriatic
* Reflexes– brisk
* Skin/mucous– Very dry skin, dry mouth
* GI/GUT– quiet bowel sounds, urinary retention
186
Anticholinergic What eg can you give?
TCAs(weakly anticholinergic)
Antihistamines(diphenhydramine, hydroxyzine)
Benztropine(CogentinTM)
Atropineand cyclopentolate (mydriatic eyedrop)
Diphenoxylate-atropine(LomotilTM)
Many neuroleptics(chlorpromazine, olanzapine)
187
Anticholinergic What is the treatment of the Anticholinergic toxidrome?
* ABC: Secure airway if low GCS
* Consider activated charcoal 1 g/kg (max 50 g) PO if ETT in
* Vitals:
* a.Temp:Water spray and cooling fans for hyperthermia
* b.LowBP:
* CNS: Lorazepam for agitation/fits(do not use haloperidol like in adults)
* Other: Consider physostigmine if both peripheral and
* central toxicity (delirium) is present..allowsmore ACH to hit end organreceptors..doesincrease risk of asystoli. Only if drug was a true anticholinergic drug
188
What is the treatment of the TCA overdose toxidrome?
189
* ABC: Secure airway if low GCS
* Consider activated charcoal 1 g/kg (max 50 g) PO if ETT in
* Vitals:
* a.Temp:Water spray and cooling fans for hyperthermia
* b.LowBP:Saline bolus/ Norepinephrine
* c.ECG:IfwideQRS,arrhythmia – Na HCO3 2 meq/kg
* CNS: Lorazepam for agitation/fits(do not use haloperidol like in adults OR phenytoin)
* Other: Consider physostigmine if both peripheral and
* central toxicity (delirium) is present..allowsmore ACH to hit end organreceptors..doesincrease risk of asystoli. Only if drug was a true anticholinergic drug
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