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Acute care Flashcards

1
Q

ETT size

A

(Age / 4) + 4 = uncuffed ETT size

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2
Q

Cholinergic drugs

A
  • organophosphates
  • carbamates (neostigmine, pyridostigmine)
  • alzheimer’s drugs e.g. donepezil
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3
Q

Cholinergic toxidrome

A

DUMBELLS

  • diaphoresis
  • urination
  • miosis
  • bronchorrhea/ bradycardia
  • emesis
  • lacrimation
  • lethargy
  • salivation
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4
Q

Cholinergic toxidrome management

A
  • 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
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5
Q

Anticholinergic drugs

A
  • TCAs (weakly)
  • antihistamines
  • benztropine
  • atropine and cyclopentolate
  • many neuroleptics
  • Jimson weed
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6
Q

Anticholinergic toxidrome

8

A
  • 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
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7
Q

Management of anticholinergic

A
  • 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)
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8
Q

Sympathomimetic drugs

A
  • cocaine
  • amphetamine/meth
  • MDMA
  • ephedrine
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9
Q

Sympathomimetic toxidrome

A
  • mydriasis
  • diaphoresis (different than anticholinergic!!)
  • hypertension
  • tachycardia
  • seizures
  • hyperthermia
  • psychosis
  • agitation
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10
Q

Management sympathomimetic

A
  • activated charcoal if within 1 hr
  • HTN –> lorazepam, phentolamine
  • hyponatremia - fluid restriction or 3% NS
  • agitation -> lorazepam
  • hyperthermia –> cool water mist and fans
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11
Q

LSD vs. PCP

A

LSD: tachy, widened pupils, diaphoresis, visual hallucinations
PCP: HTN, narrowed pupils, hyperthermia, nystagmus and rigidity

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12
Q

Serotonin syndrome

A 
<12hrs
SHIVERS
- shivering
- hyperthermic
- increased reflexes/clonus
- vitals unstable
- encephalopathy
- restless
- sweating
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13
Q

Neuroleptic Malignant Syndrome

A 
3-4 days
FEVER
- fever
- encephalopathy
- vitals unstable
- elevated enzymes (elevated CPK)
- rigidity of muscles
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14
Q

Antidepressants acute toxicity

  • citalopram
  • venlafazine
  • buproprion
  • quetiapine
A
  • citalopram/escitalopram: seizures, proloned QT
  • venlafaxine: serotonin syndrome, prolonged QT and QRS
  • buprioprion: prolonged QT and QRS, seizures
  • quetiapine: prolonged QT and QRS, hypotension
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15
Q

Opioid toxidrome

A
  • bradycardia
  • hypotension
  • resp depression
  • miosis
  • coma
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16
Q

activated charcoal indications

A
  • 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
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17
Q

Activated charcoal fails if…

A
  • Potassium
  • hydrocarbons
  • alcohols
  • iron
  • lithium
  • solvents
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18
Q

Intralipid antidote for…

A
  • for life-threatening Iv overdosis of local anesthetics, buproprion, amitiptyline
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19
Q

Antidotes

  • iron
  • CO
  • pesticide
  • nifedipine
  • amitryptyline
  • methanol
  • glyburide
A 
Iron= Deferoxamine
Carbon monoxide= Oxygen
Pesticide	=Atropine
nifedipine= Glucagon (textbook but not real life)
amitriptyline=Sodium bicarb
methanol=Fomepizole (or ethanol)
Glyburide=Gluocse
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20
Q

Hydrocarbons e.g. gasoline, nail polish remover, lighter fluid
- management

A
  • 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)
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21
Q

Metformin overdose

A

lactic acidosis

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22
Q

glyburide/sulfonylurea management

A
  • charcoal if < 2hrs

- manage hypoglycemia with IV dextrose

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23
Q

Tylenol overdose stages

toxic dose is 150mg/kg or 7-8 g in an adult

A
  1. 0-24hrs: asymptomatic or N+V
  2. 24-72hrs: RUQ pain and onset of hepatocellular injury
  3. 72-96hrs: maximal hepatotoxicity, deaths
  4. > 4 days: recovery
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24
Q

Tylenol overdose management

A
  • activated charcoal within 1 hr (not if sedated or suspect GI obstruction)
  • NAC doing based on nomogram, best if started within 8hrs
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25
Q

Salicylate poisoning

A
  • respiratory alkalosis
  • anion gap metabolic acidosis –> pulmonary/cerebral edema
  • N+V, GI bleed
  • tinnitus or hearing loss
    hyperglycmemia –> hypoglycemia
  • diaphoresis
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26
Q

Management salicylate poisoning

A
  • charcoal up to 6hrs
  • glucose to all pts with altered mental status
  • treat hypokalemia
  • alkalinize serum (to prevent needing dialysis)
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27
Q

Iron poisoning

- stages

A
  1. 30 min- 6hrs: N+V+D
  2. 6-12hrs - “quiescent”
  3. 12-24hrs - metabolic acidosis, shock, GIB, coagulopathy, resp failure
  4. 2-3 days: ARDS, liver failure
  5. 3-4 weeks: GI stricutre at gastric outlet
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28
Q

Management of iron poisoning

A
  • fluid resuscitation
  • whole bowel irrigation if tablets seen on AXR or if < 6hrs form ingestion (textbook answer)
  • Iv deferoxamine must be giver early
29
Q

Toxic alcohols

- lab findings

A
  • Isopropyl alcohol: ketosis without acidosis
  • high osmolar gap = osmolality - (2x Na +gluc + BUN)
  • wide anion gap acidosis for methanol and ethylene glycol
30
Q

TCA overdose (features)

A
  • wide QRS (and qt prolongation)
  • weakly anticholinergic
  • sedation
  • hypotension
  • seizures
31
Q

TCA overdose management

A
  • activated charcoal
  • frequently require intubation because obtunded
  • sodium bicarb for QRS > 100
  • norepi if hypotensive
32
Q

One-tablet toxins

A

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

33
Q

Prevention of submersion injuries - most effective strategy

A
  • 4 sided fence with self-locking, self-closing gates
34
Q

Risk factors for submersion injuries

A
  • leaving children unattended
  • alcohol or drug abuse
  • limited swimming ability
  • underlying medical condition (seizure disorder, toxin, prolonged QT, syncope)
35
Q

Indications for cervical spine immobilization in submersion injury

A
  • does not delay removal from water

- certain circumstances: diving, alcohol or substances, trauma

36
Q

Investigations in drowning

A
  • arterial blood gas
  • electrolytes, urea, creatinine
  • CXR for signs of ARDS
  • ECG
  • ethanol level
  • core temperature
37
Q

Good prognostic factors in submersion

A 
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
38
Q

Complications of submersion

A
  • ARDS
  • pulmonary edema
  • PNA
  • cerebral edema leading to increased ICP
  • trauma
  • hypothermia
39
Q

Hypothermia

- definition and associated sx

A
  • core temp < 35C
  • accompanied by hypoglycemia, hypocalcemia, hypokalemia, metabolic acidsois
  • associated with pancreatitis
40
Q

ECG findings in hypothermia

A
  • marked sinus bradycardia
  • first degree AV block
  • Osborn or J waves
  • prolonged QT
41
Q 
Principles of rewarming 
- pulseless
- good pulse
- VF
drugs
A

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

42
Q

Heatstroke - diagnosis, sx and management

A

Core T>40C with CNS dysfunction
- headache, disorientation, dizziness, weakness, gait disturbance
Mgmt: cool until 38.5, fluid and salt replacement orally

43
Q

Complications of heatstroke

A
  • hyponatremia
  • seizure
  • rhabdomyolysis
  • DIC
  • multisystem organ failure
44
Q

Burn classification

  1. superficial
  2. superficial partial thickness
  3. deep partial thickness
  4. full thickness
A
  1. epidermis only - red, pain, no blisters
  2. epidermis and 1/2 dermis - pink, pain, moist, blisters
  3. epidermis and >1/2 dermis - pale, dry, less tender, speckled; often need grafts
  4. subcutaneous tissue - pale, charred leathery, non-tender - most require grafting
45
Q

Indications for early intubation in burns/fire

A
  • carbonaceous sputum
  • singed nasal hairs
  • soot in airway
  • hoarseness
  • drooling
46
Q

Parkland formula (for children >= 5)

A
  • 4cc/kg/BSA over 24hrs with 1st half in 8hrs, 2nd hafl over 16hrs,
  • add maintenance to Parkland!
    (use NS or ringer’s lactate)
47
Q

Admission criteria for burns

11

A
  • 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
48
Q

High tension wire injury

A
  • muscle damage
  • compartment syndrome
  • rhabdo
  • ARF
  • CNS injury common
  • VF/arrest common
    monitor U/A and ECG
49
Q

carbon monoxide diagnosis and management

A
  • 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
50
Q

cyanide poisoning antidote

A
  • hydroxycobalamin kit

- indicated if increased lactate or decreased BP

51
Q

5 reasons to intubate:

A
  • airway patency
  • airway protection
  • resp distress/failure/arrest
  • cardiac dysfunction
  • procedures
52
Q

DOPE mnemonic

A

displacement
obstruction
PTX
equipment

53
Q

Ventilation settings to improve 1. oxygenation

2. ventilation

A 
O2:
- increase PEEP
- increase FiO2
CO2:
- increase rate
- increase tidal volume
54
Q

5 causes of hypoxemia

A
  1. low FiO2
  2. hypoventilation
  3. V/Q mismatch
  4. shunt
  5. impaired alveolar-capillary diffusion
55
Q

Severe/impending failure status asthmaticus treatment

A
  • 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
56
Q

Pediatric ARDS

- mod-severe management summary

A
  1. Vt<6mL/kg
  2. plateau pressure <28-32cm H20
  3. generous PEEP (up to 10-15cm H20
  4. HFOV = rescue
  5. permissive hypercapnia
  6. target sat 88-92
  7. consider prone positioning
  8. prevent fluid overload
57
Q

Shock examples

A
  • hypovolemic: dehydration, anemia
  • obstructive: tension PTX, tamponade, PE
  • cardiogenic: myocarditis, arrhythmia
  • distributive: anaphylaxis, sepsis
  • dissociative: CO/cyanide poisoning
  • adrenal crisis
58
Q

Shock definition

A

inadequate delivery of oxygen to meet demand

59
Q

Defibrillation doses

Epi resusc dose

A
  1. start with 2J/kg
  2. 2nd dose 4J/kg

Epi 0.01mg/kg = 0.1mL/kg of 0.1mg/mL (1:10,000)

60
Q

Bradycardia with a poor pulse HR

A
  • chest compression if < 60

- give epi 0.01mg/kg

61
Q

Indications for adenosine

A
  • SVT if have IV in place

- consider in wide complex tachy if regular and monomorphic if not in shock

62
Q

Synchronized cardioversion dosing

A
  • begin with 0.5-1J/Kg

- increase to 2J/kg

63
Q

Status epilepticus algorithm

A
  1. benzo - IV preferred
  2. repeat benzo - IV preferrred
  3. fos/pheny or phenobarb load
  4. other agent not given in 3
  5. midazolam infusion
64
Q

cerebral perfusion pressure

A

MAP - ICP

65
Q

Management of increased ICP

A
  • 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
66
Q

Goals for preventing 2ndary injury in TBI

A

avoid: hypotension (most impt), hypoxia, hyperthermia, hyponatremia, hypo/hypercapnia, hypo/hyperglycemia

67
Q

Apnea test in NDD

A
  • final PaCO2>= 60
  • final PaCO2>= 20 above pre-test
  • final pH<= 7.28
  • absence of resp effort
68
Q

2 ways to reduce pulled elbow

A
  1. hyperpronation

2. supination + flexion

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