Acute Care Flashcards
Name some types of cholinergics
Organophosphates (pesticides such as sarin “nerve” gas, dursban in RaidTM and malathion)
Carbamates (neostigmine, pyridostigmine, pesticides
such as aldicarb)
Alzheimer’s drugs (DonepezilTM)
Name some symptoms of cholinergic exposure
Diaphoresis Urination Miosis Bronchorrhea / Bradycardia Emesis Lacrimation Lethargy Salivation
Secretions everywhere
Treatment for cholinergic syndrome
100% oxygen
Early endotracheal intubation (avoid succinylcholine!)
PPE, remove clothing and vigorously irrigate skin
Atropine 0.05 mg/kg IV/IM/IO bolus Q5min until
secretions and wheezing stops
Inhaled iptratropium (AtroventTM)
Pralidoxime (2-PAM) 25 mg/kg IV with atropine
Examples of Anticholinergic Drugs
TCAs (weakly anticholinergic)
Antihistamines (diphenhydramine, hydroxyzine) Benztropine (CogentinTM)
Atropine and cyclopentolate (mydriatic eyedrop) Diphenoxylate-atropine (LomotilTM)
Many neuroleptics (chlorpromazine, olanzapine)
Signs and Symptoms of anticholinergic syndrome
tachycardia first symptom
absent bowel sounds
Dry as a Bone (dry mouth, urinary retention)
Hot as a desert (hyperthermia)
Blind as a bat (mydriasis-dilated pupils)
Red as a beet (flushed skin)
Mad as a hatter (confused)
Management of anticholinergic overdose
Sodium bicarbonate if prolonged QRS (TCAs)
Lorazepam for agitation
Water spray and cooling fans for hyperthermia
Consider activated charcoal 1 g/kg (max 50 g) PO
Consider physostigmine if both peripheral and central toxicity (delirium) is present
What are examples of sympathomimetic drugs
Cocaine
Amphetamine / Methamphetamine
MDMA (ecstasy)
Ephedrine
What are the symptoms pf sympathomimetic drug exposure
Mydriasis Diaphoresis (MAIN DIFFERENCE FROM ANTICHOLINERGICS) Hypertension Tachycardia Seizures Hyperthermia Psychosis Severe agitation
Ecstasy specific Symptoms
HTN (HTN emergencies, ICH) Hyperthermia (rhabdo, DIC) Hyponatremia (seizures) Serotonin syndrome Cardiac ischemia Hepatotoxicity
Ecstasy Management
HTN: lorazepam 1 mg IV or phentolamine (you don’t give anti-hypertensives)
Hyponatremia (Fluids restriction or 3% NS)
Activated charcoal if within 1 hour
Agitation: lorazepam 1 mg IV
Hyperthermia: cool water mist and fans
LSD Specific Symptoms
Rapid oral absorption with symptoms appearing at 30-60 min and lasting up to 12 hours
One of the most potent HALLUCINOGENS Mydriasis HTN ↑RR ↑HR diaphoresis hyperreflexia
Massive overdose results in hyperthermia, autonomic dysregulation, vomiting, respiratory arrest, ICH
PCP specific symptoms
seizures and delirium
Fluctuating behavior with delirium, paranoia, agitation Nystagmus while awake
Dystonic posturing, muscle rigidity, myoclonus
Serotonin syndrome Symptoms
Serotonin Syndrome
< 12 hours
Increased: BP,RR,HR,T
Pupils: Enlarged
Mucosa: Sialorrhea
Skin: Diaphoresis
Neurologic: Increased Reflexes (LE), increased Tone
Mental Status: Agitation
NMS Symptoms
Time course: 3-4 days
< 12 hours
Increased BP,RR,HR,T
Pupils: Normal
Mucosa: Sialorrhea
Skin: Diaphoresis
Neurologic: Rigid
Mental Status: Stupor
Opioid Toxidrome Symptoms
Bradycardia Hypotension Respiratory depression Miosis Coma
Treatment of Opioids
Naloxone (IV or IN)
Should see an effect in seconds
Ensure patent airway and adequate ventilation
What drug ingestion causes these symptoms?
Promoted online as a treatment for opioid withdrawal (?)
Produces euphoria in overdose
Prolongs QT and QRS intervals
Respiratory depression
Highly toxic to young child in overdose
Not detected in urine drug screen
Loperamide (Kratom)…Immodium
anticholinergic
but also binds to opioid mu receptors
very toxic to young children
in therapeutic doses does not cross BBB - overdose will cross and hit mu receptors
When should you NOT use charcoal?
Avoid in severe caustic ingestion
Compromised airway reflexes
>1hr from ingestion
What ingestions is charcoal not effective for?
Potassium Hydrocarbons Alcohols Iron Lithium Solvents
Treatment for lidocaine overdose?
Lorazepam and 20% intralipid
What can you use IV lipid for?
For life-threatening overdoses of local anesthetics (iatrogenic), bupropion, amitriptyline
Antidote for Iron?
Deferoxamine
Antidote for carbon monoxide?
oxygen
Antidote for pesticide?
atropine
cholinergic
Antidote for Nifedipine?
Glucagon
Antidote for Amitripytline?
Sodium Bicarb…for QRS >100
Antidote for methanol?
Fomepizole
Antidote for glyburide?
Glucose
What are some examples of Hydrocarbons?
Gasoline, nail polish remover, lighter fluid common
Main complication of hydrocarbon ingestion?
Aspiration is common and pulmonary toxicity accounts for most fatalities
Changes seen 2-8 hours post
Deterioration in 24-48 hours
Perihilar infiltrates
Pneumatoceles
Treatment of Hydrocarbon Ingestion?
Stat CXR and repeat in 4-6 hours post-ingestion…
If both look good you can send them home
Oxygen
+/- bronchodilators
Can d/c at 4-6 hours if asymptomatic and normal CXR
Supportive Care
Metformin ingestion can cause what complication?
Lactic Acidosis
Usually normal Glucose
List 4 drugs that cause hypoglycemia
Glyburide
Beta blockers
Ethanol
Salicylates
Acetaminophen toxic ingestion occurs at what dose?
Toxic metabolite is NAPQI
Toxic dose is 150 mg/kg (7.5 grams in adult)
Hepatoxicity reported in children given > 90 mg/ kg/day for more than 1 day
What complications can occur secondary to Tylenol ingestion?
Anion gap metabolic acidosis
Acute tubular necrosis
Fulminant liver failure
What are the stages of Tylenol ingestion?
Stage I (0-24 hrs): Asymptomatic or nausea/ vomiting Stage II (24-72 hrs): Right upper quadrant pain and onset of hepatocellular injury Stage III (72-96 hrs): Maximal hepatoxicity; Most deaths occur during this phase Stage IV (> 4 days): Recovery
Treatment of Acetaminophen Ingestion
Activated charcoal within 1 hour
NAC dosing based on Rumack-Matthew nomogram (nomogram only works for up to 8h)
Best outcomes if NAC started within 8 hours
Follow transaminases, INR/PTT, RFTs, lipase
What are examples of salicylates?
ASA Bismuth salicylate (antidiarrhoeal agent) Methyl salicylate (Rub A535TM) Salicylic acid (wart removal)
What are the symptoms of salicylates overdose?
Hyperpnea / tachypnea….respiratory alkalosis
AG metabolic acidosis…pulmonary/cerebral edema Nausea, vomiting, gastrointestinal bleed
Tinnitus (early) or hearing loss
Hyperglycemia…hypoglycemia
Diaphoresis
Management of salicylate overdose
Charcoal up to 6 hours (bezoar formation)
Glucose to all patients with altered mental status regardless of peripheral glucose
Treat hypokalemia: because it can impair alkalinization
Alkalinize serum to urine pH between 7.5 - 7.6 to “trap”
salicylate anions in blood and renal tubule
Hemodialysis - indicated for CNS symptoms
Investigations for Iron Ingestion
Toxic quantity calculated as elemental iron
Ferinsol bottle and “gummy bears” not toxic
Serum iron within 4-6 hours of ingestion
Abdominal x-ray suggestive
If no opacities are seen, patient is unlikely to benefit from gastric decontamination
Examples of radiopaque drugs
Chloral hydrate Opioid packets (latex) Iron and other heavy metals Neuroleptics (early) Sustained-release tablets / Salicylates (early)
Stages of Iron Toxicity
Stage I (30 min-6 hrs): Nausea, vomiting, diarrhea Stage II (6-12 hrs):“Quiescent” phase Stage III (12-24 hrs): Metabolic acidosis: Shock, GI haemorrhage, coagulopathy, respiratory failure Stage IV (2-3 days): ARDS, liver failure Stage V (3-4 wks): GI strictures at gastric outlet
Clues to iron ingestion
GI symptoms
Acidosis
Multiorgan failure
Iron Management
No role for either charcoal or gastric lavage
Fluid resuscitation essential
WBI if tablets seen on AXR or if < 6 hours from ingestion (textbook answer only!)
IV deferoxamine (DFO) is the antidote of choice and must be given early
Dose is 15 mg/kg/hr until urine color clears
Isopropyl Alcohol Ingestion Symptoms
The most common toxic alcohol ingested
Hallmark is ketosis without acidosis
As little as 2 cc can lead to symptoms
Mainly causes inebriation that peaks in 1-2 hours
Management of Isopropyl Alcohol ingestion
Rule out co-ingestion with ethanol, methanol or ethylene glycol ingestion
No role for activated charcoal
No role for ADH inhibition with fomepizole or ethanol
Discharge after 2 hours if asymptomatic
List some things methanol is found in
windshield wash, bingo dabbers
Signs and Symptoms from methanol ingestion
Less inebriating than ethanol
Toxicity associated with as little as one teaspoon!
Formate causes retinal injury (blurring, central scotoma, blindness)
Normal methanol level doesn’t rule out ingestion Profound AG acidosis presents late (> 24 hrs)
What is ethylene glycol found in?
antifreeze, paints, brake fluid
What is the management of ethylene glycol ingestion
Colorless, odorless, sweet taste Inebriation with no odor of ethanol Metabolic acidosis:cardiac decompensation Hypocalcemia: prolonged QTc Oxalate crystals appear late
Clues to Toxic Alcohol Exposure
Inebriation
Odor
Osmolal gap or Acidosis
Treatment of Toxic Alcohol Ingestion
Wash skin if exposed
Fomepizole or ethanol based on ingestion history, OG, serum level
Hemodialysis if high AG acidosis or end-organ damage
Cofactor therapy with folic acid or leucovorin
Thiamine 100 mg and pyridoxine 50 mg
Symptoms of TCA ingestion
Inhibit norepinephrine and serotonin reuptake
Block cardiac fast Na channels- wide QRS
Block muscarinic receptors- weakly anticholinergic
Block histamine receptors- sedation
Block alpha receptors- hypotension
Block GABA receptors- seizure
What is the management of TCA ingestion
Activated charcoal
Frequently require intubation because obtunded
NaHCO3 for QRS > 100 because of significant morbidity and mortality
Norepinephrine infusion if hypotensive
Physostigmine contraindicated
Symptoms of Carbon Monoxide Poisoning
Initially headache, dizziness, nausea, confusion, seizure, syncope, coma but don’t correlate with COHb level
Dysrhythmia and cardiac arrest in < 30%
Diagnosis of Carbon Monoxide Poisoning
Standard pulse oximetry and arterial pO2 normal
COHb < 5% (non-smokers) and < 10% (smokers)
Carboxyhemoglobin (COHb) level > 3% consistent with toxic inhalation
Check cyanide level
Follow ECG and cardiac enzymes
Management of CO exposure
Remove from source and rule out smoke inhalation
Treat if COHb > 10% if 100% FiO2
Hyperbaric oxygen (best if < 6 hrs of exposure) if:
- COHb > 25% (> 15% in pregnant female or child)
- Neurologic Symptoms (loss of consciousness,
seizure, cardiac ischemia, cerebellar deficits)
When should you THINK of cyanide poisoning?
House fire
CO poisoning
Persistent lactic acidosis with CO poisoning
Cerebral edema, seizures, coma House fire (wool, plastics), stone fruit pits, cassava root, nitroprusside infusion
Management of Cyanide poisoning
Antidote is hydroxycobalamin kit
Indicated if increased lactate or decreased BP
Transiently reddening of skin and urine (chromaturia)
Adequate oxygenation necessary often with mechanical ventilation
Examples of CCB
Dihydropyridines: amlodipine, nifedipine
Non-dihydropyridines: verapamil, diltiazem (high glucose)
Signs and Symptoms of CCB ingestion
Ingestion of at least 5x normal dose can develop severe intoxication
Hypotension and bradycardia can be profound and refractory
May maintain pristine mental status despite hypotension
Precipitous deterioration is common so early aggressive therapy is needed
Management of CCB ingestion
Atropine (0.02 mg/kg) 0.5-1.0 mg IV Q2-3 minutes
Calcium gluconate bolus or infusion
Glucagon 5 mg IV but causes severe N/V
Norepinephrine is initial vasopressor of choice
High dose insulin euglycemic therapy (has positive inotropic effects)
Insulin 1 unit/kg bolus —> 1-10 units/kg/hr + K Must add 2.5 mL/kg of IV D10W
Laundry Detergent Capsules Symptoms
Vomiting, drooling, respiratory distress
Airway compromise and esophageal perforation
Skin burns
Management of ingestion of laundry detergent capsules
supportive
ave them drink a glass of water
Symptoms of nicotine overdose
Onset of vomiting, diaphoresis, confusion within 2 hrs Seizures, initial ↑BP, ↑RR, ↑HR ⇒ ↓BP, ↓RR, ↓HR
Who is most at risk for a submersion injury
Males > Females
Children < 5 years at greatest risk
Usually during the summer months
Associated with hypothermia and trauma
Most common cause of death in children aged 1-4
Trauma
Most effective strategies for preventing submersion injuries.
Most effective prevention strategy is a four-sided self-closing fence with a self-locking gate
Toddlers should always be within arm’s length of an adult, even in a bathtub
1 adult per baby and 1 adult per 2 young children
Swimming programs for children < 4 years do not
decrease rates of drowning
Who should wear a PFD?
Should be worn by all infants at least 9 kg
Babies who cannot sit unsupported are too young to wear PFDs
Water wings, inflatable undies, pool noodles are not safety devices
Risk Factors for Submersion injury
Leaving children unattended
Alcohol or drug abuse (50% of adult drownings) Limited swimming ability
Underlying medical conditions(?):
- Seizure disorder, toxin, prolonged QT, syncope
Factors for good prognosis after submersion injury
Immediate bystander CPR is most important factor influencing survival
What are other good prognostic indicators?
- Return of spontaneous circulation in < 10 min
- Submersion < 5 min
- Pupils equal and reactive at scene
- Normal sinus rhythm at scene
What are poor prognostic factors for submersion injury
What are poor prognostic indicators?
- Delayed CPR
- Return of spontaneous circulation > 25 min
- Submersion > 10 min
What are complications of submersion injury?
ARDS Pulmonary edema Pneumonia Cerebral edema leading to increased ICP Trauma Hypothermia
Definition of Hypothermia
Defined as core temp < 35 C
Metabolic disturbances from hypothermia
Shivering stops at core temp < 32 C
Accompanied by hypoglycemia, hypocalcemia, hypokalemia, metabolic acidosis
Associated with pancreatitis
Features of hypothermia at 31-32 C
- Normal ECG, ↑ HR, ↑ BP, loss of shivering
Features of hypothermia at 28-31 C
- ↓ HR, ↓ BP, flipped T, atrial fibrillation, sluggish, dilated pupils
Features of Hypothermia at <28C
- absent pulse and BP, VF, coma, fixed dilated pupils
EKG findings in hypothermia
Marked sinus bradycardia
First degree AV block
Osborn or J waves Associated with prolonged QT and bradycardia
Seen in core T < 32 C
Special CPR Considerations with hypothermia
Avoid CPR in T < 28 and good pulse
If pulseless → CPR
If VF → defibrillation x 3 but no more until T > 30
Drugs rarely effective until T > 30
Can trigger dysrhythmia if T < 30 just by bumping bed!
