Crit Care 4: Pages 82-86 Flashcards
What is shown by the arrows
Electrocardiogram showing Osborne waves associated with hypothermia. They are best seen in the inferior and lateral chest leads. Osborne waves are defined by the shoulder or “hump” between QRS and ST segments.
Ethanol :Common Sources, Major Findings,Anion Gap (yes/no),Osmolar Gap(yes/no), Antidote.
Common Sources: Alcoholic beverages
Major Findings: CNS depression Nausea, emesis
Anion Gap: Possible
Osmolar Gap: Yes
Antidote:Supportive care
Isopropyl Alcohol :Common Sources, Major Findings,Anion Gap (yes/no),Osmolar Gap(yes/no), Antidote.
Common Sources: Rubbing alcohol, Disinfectants, Antifreeze
Major Findings: CNS depression ,Ketone elevation
Anion Gap: no
Osmolar Gap: yes
Antidote:Supportive care
Methanol:Common Sources, Major Findings,Anion Gap (yes/no),Osmolar Gap(yes/no), Antidote.
Common Sources: Windshield wiper fluid, De-icing solutions, Solvents, “Moonshine”
Major Findings: CNS depression, Vision loss, Hypotension
Anion Gap: Yes
Osmolar Gap: Yes
Antidote:
Fomepizole
Ethanol (only if fomepizole is not available)
HD for severe acidemia, very large ingestions, severe CNS depression, and any visual impairment
Ethylene Glycol:Common Sources, Major Findings,Anion Gap (yes/no),Osmolar Gap(yes/no), Antidote.
Common Sources: Antifreeze,De-icing solutions,Solvents
Major Findings:
CNS depression, AKI, Hypocalcemia, Hypotension
Anion Gap:Yes
Osmolar Gap: Yes
Antidote:
Fomepizole
Ethanol (only if fomepizole is not available)
HD for severe acidemia, very large ingestions, severe CNS depression, AKI, and systemic collapse
How does ethylene glycol leadto kidney damage
ethylene glycol is metabolized by alcohol dehydrogenase to oxalic acid, which crystalizes in the renal tubules and can lead to permanent kidney damage
Symptoms of CO poisoning
headache, nausea, malaise, confusion, syncope, seizures, or coma. Patients with coronary artery disease may develop signs and symptoms of cardiac ischemia.
Smokers may have up to __% to __% carboxyhemoglobin
10-15
the half-life of carboxyhemoglobin is
300 minutes if patients are breathing ambient air, 90 minutes if breathing 100% oxygen, and 30 minutes if given hyperbaric oxygen
Patients with high levels of carboxyhemoglobin (____% and greater) and ____ should be treated with hyperbaric oxygen if possible.
25%
evidence of organ ischemia
MOA for cyanide poisoning
It inhibits cellular respiration by binding to cytochrome oxidase a3 in the mitochondria, blocking the cells’ ability to use oxygen for aerobic metabolism
What is the oxyhemoglobin saturation in cyandide poisoning
normal- but patient will have signs of hypoxia
Symptoms of Cyanide Poisoning
headache, anxiety, nausea, and either a metallic or bitter almond odor and taste.
More severe or prolonged exposure can lead to coma, seizures, liver or kidney injury, vomiting, ischemic pain, rhabdomyolysis, and death.
Serum lactate elevation is a 1.____ but non 2.____ marker for cyanide toxicity.
- Sensative
- Specific
A normal lactate concentration effectively rules out significant cyanide exposure.
Tx for cyanid poisoning
Hydroxocobalamin- binds to cyanide to produce cyanocobalamin, which is soluble, nontoxic, and readily excreted. The usual dose is 5 g for an adult.
Thiosulfate- donates sulfur to combine with cyanide, producing harmless thiocyanate
Manifestations of sympathomimetic overdose (Cocaine,Amphetamines,Ephedrine,Caffeine)
- Tachycardia
- Hypertension
- Diaphoresis
- Agitation
- Seizures
- Mydriasis
Manifestations of Cholinergic toxicity (Organophosphates (insecticides, sarin),Carbamates,Physostigmine,Edrophonium,Nicotine)
- “SLUDGE” (salivation, lacrimation, increased urination and defecation, gastrointestinal upset, and emesis)
- Confusion
- Bronchorrhea
- Bradycardia
- Miosis
Manifestations of anticholinergic toxicity ( Antihistamines,Tricyclic antidepressants, Anti-Parkinson agents, Atropine, Scopolamine)
- Hyperthermia
- Dry skin and mucous membranes
- Agitation, delirium
- Tachycardia, tachypnea
- Hypertension
- Mydriasis
Opiod overdose symptoms
- Miosis
- Respiratory depression
- Lethargy, confusion
- Hypothermia
- Bradycardia
- Hypotension
How do you titrate naloxone gtt
To respiratory rate goal
(They told me 8 of less needs it at Denver Health and we titrated to 12-16 respirations per minute in my patient here)
Benzo overdose antidote, why do you need to be careful when administring, are acute or chronic users more likely to expereince this?
flumazenil , reversing the effect of benzodiazepines can lead to life-threatening CNS activation, including seizures, which are most likely in patients receiving benzodiazepines chronically.
Acetaminophen overdose
Key clinical findings
Tx
- Key clinical findings:↑ liver chemistry studies, ↑ Cr, ↑ INR, encephalopathy, cerebral edema, vomiting
- Tx: N-acetylcysteine, Transfer to liver transplant center if severe
Salicylates overdose
Key clinical findings
Tx
- Key clinical findings: Mixed respiratory alkalosis/anion gap metabolic acidosis, tinnitus, agitation, confusion, hyperthermia
- Tx: Forced diuresis, bicarbonate infusion, glucose, Target urine pH 7.5-8.0; hemodialysis if acute kidney injury or severe toxicity
β-Blocker, calcium channel blocker overdose
Key clinical findings
Tx
- Key clinical findings: ↓ HR, ↓ BP, heart block; altered mental status if β-blocker
- Tx: Atropine 1 mg IV up to 3 doses, glucagon, calcium chloride, vasopressors, cardiac pacemaker (if indicated), high-dose insulin and glucose, IV lipid emulsionTreatments may be added sequentially or initiated simultaneously depending on severity of case and response to treatment
Digoxin overdose
Key clinical findings
Tx
- Key clinical findings: ↓ HR, arrhythmia, nausea, emesis, abdominal pain, confusion, weakness
- Tx:Digoxin-specific antibody, Use of antibody lowers K+; hemodialysis not effective
TCA overdose
Key clinical findings
Tx
- Key clinical findings: ↓ BP, sedation, seizure, anticholinergic signs, prolonged QRS, arrhythmia
- Tx:Bicarbonate infusion titrated to QRS duration; benzodiazepines for seizure, Physostigmine contraindicated
Antihistamines overdose
Key clinical findings
Tx
- Key clinical findings:Anticholinergic signs, including agitation and seizures
- Tx:Benzodiazepines; physostigmine if isolated anticholinergic overdose, Physostigmine use requires continuous cardiac monitor and bedside atropine
Sulfonylurea overdose
Key clinical findings
Tx
- Key clinical findings: ↓ glucose, confusion, seizure, anxiety, diaphoresis, tremor
- Tx: IV glucose + octreotide, glucagon IM = temporizing, Monitor for ↓ glucose for 48 hours if large ingestion
Metformin overdose
Key clinical findings
Tx
- Key clinical findings: ↑ lactate, abdominal pain
- Tx: Hemodialysis for severe ↓ pH or acute kidney injury, Glucose usually normal if isolated metformin ingestion
Lithium overdose
Key clinical findings
Tx
- Key clinical findings: GI distress, confusion, ataxia, tremor, myoclonic jerks, diabetes insipidus
- Tx: Hemodialysis if lithium level >4 mEq/L (4 mmol/L) or severe symptoms, Serum level can guide need for hemodialysis, confirm diagnosis
SSRI/SNRI overdose
Key clinical findings
Tx
- Key clinical findings: Agitation, myoclonus, ↑ reflexes, rigidity, fever, ↑ HR
- Tx: Benzodiazepines, cyproheptadine if severe, Venlafaxine has ↑ cardiac toxicity
