Acute care Flashcards
ETT size
(Age / 4) + 4 = uncuffed ETT size
Cholinergic drugs
- organophosphates
- carbamates (neostigmine, pyridostigmine)
- alzheimer’s drugs e.g. donepezil
Cholinergic toxidrome
DUMBELLS
- diaphoresis
- urination
- miosis
- bronchorrhea/ bradycardia
- emesis
- lacrimation
- lethargy
- salivation
Cholinergic toxidrome management
- 100% oxygen
- early endotracheal intubation (avoid succ)
- PPE, remove clothing and vigorously irrigate skin
- atropine q5 min until secretions and wheezing stops
- inhaled ipratropium
- pralidoxime with atropine
Anticholinergic drugs
- TCAs (weakly)
- antihistamines
- benztropine
- atropine and cyclopentolate
- many neuroleptics
- Jimson weed
Anticholinergic toxidrome
8
- dilated pupils
- blind as a bat
- red as a beet
- dry as a bone
- hot as a desert
- mad as a hatter
- absent bowel sounds
- tachycardia
Management of anticholinergic
- lorazepam for agitation
- water spray and cooling fans for hyperthermia
- consider activated charcoal
- if TCA with prolonged QRS –> sodium bicarb
- consider physostigmine (only pure anticholinergics)
Sympathomimetic drugs
- cocaine
- amphetamine/meth
- MDMA
- ephedrine
Sympathomimetic toxidrome
- mydriasis
- diaphoresis (different than anticholinergic!!)
- hypertension
- tachycardia
- seizures
- hyperthermia
- psychosis
- agitation
Management sympathomimetic
- activated charcoal if within 1 hr
- HTN –> lorazepam, phentolamine
- hyponatremia - fluid restriction or 3% NS
- agitation -> lorazepam
- hyperthermia –> cool water mist and fans
LSD vs. PCP
LSD: tachy, widened pupils, diaphoresis, visual hallucinations
PCP: HTN, narrowed pupils, hyperthermia, nystagmus and rigidity
Serotonin syndrome
<12hrs SHIVERS - shivering - hyperthermic - increased reflexes/clonus - vitals unstable - encephalopathy - restless - sweating
Neuroleptic Malignant Syndrome
3-4 days FEVER - fever - encephalopathy - vitals unstable - elevated enzymes (elevated CPK) - rigidity of muscles
Antidepressants acute toxicity
- citalopram
- venlafazine
- buproprion
- quetiapine
- citalopram/escitalopram: seizures, proloned QT
- venlafaxine: serotonin syndrome, prolonged QT and QRS
- buprioprion: prolonged QT and QRS, seizures
- quetiapine: prolonged QT and QRS, hypotension
Opioid toxidrome
- bradycardia
- hypotension
- resp depression
- miosis
- coma
activated charcoal indications
- within 1-2 hrs of ingestion
- can give later if drug slowly GI emptying e.g. anticholinergic
- avoid in severe caustic ingestion, compromised airway reflexes
Activated charcoal fails if…
- Potassium
- hydrocarbons
- alcohols
- iron
- lithium
- solvents
Intralipid antidote for…
- for life-threatening Iv overdosis of local anesthetics, buproprion, amitiptyline
Antidotes
- iron
- CO
- pesticide
- nifedipine
- amitryptyline
- methanol
- glyburide
Iron= Deferoxamine Carbon monoxide= Oxygen Pesticide =Atropine nifedipine= Glucagon (textbook but not real life) amitriptyline=Sodium bicarb methanol=Fomepizole (or ethanol) Glyburide=Gluocse
Hydrocarbons e.g. gasoline, nail polish remover, lighter fluid
- management
- CXR stat and repeat in 4-6 hrs post ingestion
- oxygen +/- bronchodilators
- can D/C at 4-6hrs if asymptomatic and normal CXR (watching fro perihilar infilatrates, pneumatocele and resp deterioration ver 24-48hrs)
Metformin overdose
lactic acidosis
glyburide/sulfonylurea management
- charcoal if < 2hrs
- manage hypoglycemia with IV dextrose
Tylenol overdose stages
toxic dose is 150mg/kg or 7-8 g in an adult
- 0-24hrs: asymptomatic or N+V
- 24-72hrs: RUQ pain and onset of hepatocellular injury
- 72-96hrs: maximal hepatotoxicity, deaths
- > 4 days: recovery
Tylenol overdose management
- activated charcoal within 1 hr (not if sedated or suspect GI obstruction)
- NAC doing based on nomogram, best if started within 8hrs
Salicylate poisoning
- respiratory alkalosis
- anion gap metabolic acidosis –> pulmonary/cerebral edema
- N+V, GI bleed
- tinnitus or hearing loss
hyperglycmemia –> hypoglycemia - diaphoresis
Management salicylate poisoning
- charcoal up to 6hrs
- glucose to all pts with altered mental status
- treat hypokalemia
- alkalinize serum (to prevent needing dialysis)
Iron poisoning
- stages
- 30 min- 6hrs: N+V+D
- 6-12hrs - “quiescent”
- 12-24hrs - metabolic acidosis, shock, GIB, coagulopathy, resp failure
- 2-3 days: ARDS, liver failure
- 3-4 weeks: GI stricutre at gastric outlet
Management of iron poisoning
- fluid resuscitation
- whole bowel irrigation if tablets seen on AXR or if < 6hrs form ingestion (textbook answer)
- Iv deferoxamine must be giver early
Toxic alcohols
- lab findings
- Isopropyl alcohol: ketosis without acidosis
- high osmolar gap = osmolality - (2x Na +gluc + BUN)
- wide anion gap acidosis for methanol and ethylene glycol
TCA overdose (features)
- wide QRS (and qt prolongation)
- weakly anticholinergic
- sedation
- hypotension
- seizures
TCA overdose management
- activated charcoal
- frequently require intubation because obtunded
- sodium bicarb for QRS > 100
- norepi if hypotensive
One-tablet toxins
CV collapse:
- propranolol - CV collapse + hypoglycemia
-CCB - CV collapse
- clonidine - bradycardia + CNS depression
Hypoglycemia:
- propranolol
- glyburide - hypoglycaemia
Seizures etc:
- camphor - seizures
- theophylline - seizures, dysrhtyhmia
- TCA - seizures, hypotension, dysrthyhmia
Prevention of submersion injuries - most effective strategy
- 4 sided fence with self-locking, self-closing gates
Risk factors for submersion injuries
- leaving children unattended
- alcohol or drug abuse
- limited swimming ability
- underlying medical condition (seizure disorder, toxin, prolonged QT, syncope)
Indications for cervical spine immobilization in submersion injury
- does not delay removal from water
- certain circumstances: diving, alcohol or substances, trauma
Investigations in drowning
- arterial blood gas
- electrolytes, urea, creatinine
- CXR for signs of ARDS
- ECG
- ethanol level
- core temperature
Good prognostic factors in submersion
Good prognosis: - immediate bystander CPR (most impt) - return of spontaneous circulation in < 10 min - submersion < 5 min - pupils equal and reactive at scene - normal sinus rhtyhm at scene Poor prognosis: - delayed CPR, ROSC > 25 min, submersion > 10 min
Complications of submersion
- ARDS
- pulmonary edema
- PNA
- cerebral edema leading to increased ICP
- trauma
- hypothermia
Hypothermia
- definition and associated sx
- core temp < 35C
- accompanied by hypoglycemia, hypocalcemia, hypokalemia, metabolic acidsois
- associated with pancreatitis
ECG findings in hypothermia
- marked sinus bradycardia
- first degree AV block
- Osborn or J waves
- prolonged QT
Principles of rewarming - pulseless - good pulse - VF drugs
pulseless –> CPR
avoid CPR in T<28 and good pulse
VF –> defb x 3 but no more until T>= 30
drugs rarely effective until T>= 30, dont give until 30C
Heatstroke - diagnosis, sx and management
Core T>40C with CNS dysfunction
- headache, disorientation, dizziness, weakness, gait disturbance
Mgmt: cool until 38.5, fluid and salt replacement orally
Complications of heatstroke
- hyponatremia
- seizure
- rhabdomyolysis
- DIC
- multisystem organ failure
Burn classification
- superficial
- superficial partial thickness
- deep partial thickness
- full thickness
- epidermis only - red, pain, no blisters
- epidermis and 1/2 dermis - pink, pain, moist, blisters
- epidermis and >1/2 dermis - pale, dry, less tender, speckled; often need grafts
- subcutaneous tissue - pale, charred leathery, non-tender - most require grafting
Indications for early intubation in burns/fire
- carbonaceous sputum
- singed nasal hairs
- soot in airway
- hoarseness
- drooling
Parkland formula (for children >= 5)
- 4cc/kg/BSA over 24hrs with 1st half in 8hrs, 2nd hafl over 16hrs,
- add maintenance to Parkland!
(use NS or ringer’s lactate)
Admission criteria for burns
11
- burns covering > 10% of total BSA
- full thickness burns
- electrical burns
- chemical burns
- inhalation injury
- suspected NAI
- burns to face, hands, feet, perineum, genitals or major joints
- burns in pts with preexisting medical conditions
- associated injuries
- pregnancy
- inadequate home or social evironment
High tension wire injury
- muscle damage
- compartment syndrome
- rhabdo
- ARF
- CNS injury common
- VF/arrest common
monitor U/A and ECG
carbon monoxide diagnosis and management
- normal pulse ox and arterial pO2
- COHb > 3%
- remove from source
- treat if COHb > 10% on 100% FiO2
- hyperabric oxygen (best if < 6hrs of exposure) if COHb > 25% (>20% in child), CNS symptoms
cyanide poisoning antidote
- hydroxycobalamin kit
- indicated if increased lactate or decreased BP
5 reasons to intubate:
- airway patency
- airway protection
- resp distress/failure/arrest
- cardiac dysfunction
- procedures
DOPE mnemonic
displacement
obstruction
PTX
equipment
Ventilation settings to improve 1. oxygenation
2. ventilation
O2: - increase PEEP - increase FiO2 CO2: - increase rate - increase tidal volume
5 causes of hypoxemia
- low FiO2
- hypoventilation
- V/Q mismatch
- shunt
- impaired alveolar-capillary diffusion
Severe/impending failure status asthmaticus treatment
- oxygen
- salbutamol
- systemic steroids IV
- Mg SO4
- adjuncts: ketamine, HFNC, NIPPV,
- PICU
- IM or SC epi if no IV access and sudden deterioration
avoid intubation - R/o complications e.g. PTX
Pediatric ARDS
- mod-severe management summary
- Vt<6mL/kg
- plateau pressure <28-32cm H20
- generous PEEP (up to 10-15cm H20
- HFOV = rescue
- permissive hypercapnia
- target sat 88-92
- consider prone positioning
- prevent fluid overload
Shock examples
- hypovolemic: dehydration, anemia
- obstructive: tension PTX, tamponade, PE
- cardiogenic: myocarditis, arrhythmia
- distributive: anaphylaxis, sepsis
- dissociative: CO/cyanide poisoning
- adrenal crisis
Shock definition
inadequate delivery of oxygen to meet demand
Defibrillation doses
Epi resusc dose
- start with 2J/kg
- 2nd dose 4J/kg
Epi 0.01mg/kg = 0.1mL/kg of 0.1mg/mL (1:10,000)
Bradycardia with a poor pulse HR
- chest compression if < 60
- give epi 0.01mg/kg
Indications for adenosine
- SVT if have IV in place
- consider in wide complex tachy if regular and monomorphic if not in shock
Synchronized cardioversion dosing
- begin with 0.5-1J/Kg
- increase to 2J/kg
Status epilepticus algorithm
- benzo - IV preferred
- repeat benzo - IV preferrred
- fos/pheny or phenobarb load
- other agent not given in 3
- midazolam infusion
cerebral perfusion pressure
MAP - ICP
Management of increased ICP
- increase venous drainage: HOB to 30 degrees, c-collar not too tight, head midline
- osmotic therapies: Hypertonic saline 2-5mL/kg IV
- control ICP surge:analgesia, sedation, anti-seizure, anti-pyretic, NM blockade in severe cases
- CSF removal
- mass removal eg.. hematoma
- reduce cerebral blood volume e.g. hyperventilation
- increase intracranial space
Goals for preventing 2ndary injury in TBI
avoid: hypotension (most impt), hypoxia, hyperthermia, hyponatremia, hypo/hypercapnia, hypo/hyperglycemia
Apnea test in NDD
- final PaCO2>= 60
- final PaCO2>= 20 above pre-test
- final pH<= 7.28
- absence of resp effort
2 ways to reduce pulled elbow
- hyperpronation
2. supination + flexion
