Crit Care 4: Pages 82-86

Question 1

What is shown by the arrows

Answer 1

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.

Question 2

Ethanol :Common Sources, Major Findings,Anion Gap (yes/no),Osmolar Gap(yes/no), Antidote.

Answer 2

Common Sources: Alcoholic beverages

Major Findings: CNS depression Nausea, emesis

Anion Gap: Possible

Osmolar Gap: Yes

Antidote:Supportive care

Question 3

Isopropyl Alcohol :Common Sources, Major Findings,Anion Gap (yes/no),Osmolar Gap(yes/no), Antidote.

Answer 3

Common Sources: Rubbing alcohol, Disinfectants, Antifreeze

Major Findings: CNS depression ,Ketone elevation

Anion Gap: no

Osmolar Gap: yes

Antidote:Supportive care

Question 4

Methanol:Common Sources, Major Findings,Anion Gap (yes/no),Osmolar Gap(yes/no), Antidote.

Answer 4

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

Question 5

Ethylene Glycol:Common Sources, Major Findings,Anion Gap (yes/no),Osmolar Gap(yes/no), Antidote.

Answer 5

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

Question 6

How does ethylene glycol leadto kidney damage

Answer 6

ethylene glycol is metabolized by alcohol dehydrogenase to oxalic acid, which crystalizes in the renal tubules and can lead to permanent kidney damage

Question 7

Symptoms of CO poisoning

Answer 7

headache, nausea, malaise, confusion, syncope, seizures, or coma. Patients with coronary artery disease may develop signs and symptoms of cardiac ischemia.

Question 8

Smokers may have up to __% to __% carboxyhemoglobin

Answer 8

10-15

Question 9

the half-life of carboxyhemoglobin is

Answer 9

300 minutes if patients are breathing ambient air, 90 minutes if breathing 100% oxygen, and 30 minutes if given hyperbaric oxygen

Question 10

Patients with high levels of carboxyhemoglobin (____% and greater) and ____ should be treated with hyperbaric oxygen if possible.

Answer 10

25%

evidence of organ ischemia

Question 11

MOA for cyanide poisoning

Answer 11

It inhibits cellular respiration by binding to cytochrome oxidase a3 in the mitochondria, blocking the cells’ ability to use oxygen for aerobic metabolism

Question 12

What is the oxyhemoglobin saturation in cyandide poisoning

Answer 12

normal- but patient will have signs of hypoxia

Question 13

Symptoms of Cyanide Poisoning

Answer 13

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.

Question 14

Serum lactate elevation is a 1.____ but non 2.____ marker for cyanide toxicity.

Answer 14

1. Sensative
2. Specific

A normal lactate concentration effectively rules out significant cyanide exposure.

Question 15

Tx for cyanid poisoning

Answer 15

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

Question 16

Manifestations of sympathomimetic overdose (Cocaine,Amphetamines,Ephedrine,Caffeine)

Answer 16

• Tachycardia
• Hypertension
• Diaphoresis
• Agitation
• Seizures
• Mydriasis

Question 17

Manifestations of Cholinergic toxicity (Organophosphates (insecticides, sarin),Carbamates,Physostigmine,Edrophonium,Nicotine)

Answer 17

• “SLUDGE” (salivation, lacrimation, increased urination and defecation, gastrointestinal upset, and emesis)
• Confusion
• Bronchorrhea
• Bradycardia
• Miosis

Question 18

Manifestations of anticholinergic toxicity ( Antihistamines,Tricyclic antidepressants, Anti-Parkinson agents, Atropine, Scopolamine)

Answer 18

• Hyperthermia
• Dry skin and mucous membranes
• Agitation, delirium
• Tachycardia, tachypnea
• Hypertension
• Mydriasis

Question 19

Opiod overdose symptoms

Answer 19

• Miosis
• Respiratory depression
• Lethargy, confusion
• Hypothermia
• Bradycardia
• Hypotension

Question 20

How do you titrate naloxone gtt

Answer 20

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)

Question 21

Benzo overdose antidote, why do you need to be careful when administring, are acute or chronic users more likely to expereince this?

Answer 21

flumazenil , reversing the effect of benzodiazepines can lead to life-threatening CNS activation, including seizures, which are most likely in patients receiving benzodiazepines chronically.

Question 22

Acetaminophen overdose

Key clinical findings

Tx

Answer 22

• Key clinical findings:↑ liver chemistry studies, ↑ Cr, ↑ INR, encephalopathy, cerebral edema, vomiting
• Tx: N-acetylcysteine, Transfer to liver transplant center if severe

Question 23

Salicylates overdose

Key clinical findings

Tx

Answer 23

• 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

Question 24

β-Blocker, calcium channel blocker overdose

Key clinical findings

Tx

Answer 24

• 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

Question 25

Digoxin overdose

Key clinical findings

Tx

Answer 25

• Key clinical findings: ↓ HR, arrhythmia, nausea, emesis, abdominal pain, confusion, weakness
• Tx:Digoxin-specific antibody, Use of antibody lowers K+; hemodialysis not effective

Question 26

TCA overdose

Key clinical findings

Tx

Answer 26

• Key clinical findings: ↓ BP, sedation, seizure, anticholinergic signs, prolonged QRS, arrhythmia
• Tx:Bicarbonate infusion titrated to QRS duration; benzodiazepines for seizure, Physostigmine contraindicated

Question 27

Antihistamines overdose

Key clinical findings

Tx

Answer 27

• 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

Question 28

Sulfonylurea overdose

Key clinical findings

Tx

Answer 28

• 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

Question 30

Metformin overdose

Key clinical findings

Tx

Answer 30

• Key clinical findings: ↑ lactate, abdominal pain
• Tx: Hemodialysis for severe ↓ pH or acute kidney injury, Glucose usually normal if isolated metformin ingestion

Question 31

Lithium overdose

Key clinical findings

Tx

Answer 31

• 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

Question 32

SSRI/SNRI overdose

Key clinical findings

Tx

Answer 32

• Key clinical findings: Agitation, myoclonus, ↑ reflexes, rigidity, fever, ↑ HR
• Tx: Benzodiazepines, cyproheptadine if severe, Venlafaxine has ↑ cardiac toxicity