Day 3 - EM1 Toxicology, CV Flashcards
Potential consequences of acetaminophen toxicity
Stage 1 - w/i 30 min: n/v, diaphoresis, pallor, lethargy, malaise; Stage 2 - w/i 24-72 hr: liver injury, PT & T.bili elevated, RUQ pain/tenderness; Stage 3- 72-96 hr: peak LFTs, jaundice, hepatic encephalopathy, bleeding, acute renal failure, possible multisystem organ failure or death; Stage 4 - 4 days to 2 weeks - Possible recovery
S/Sx anticholinergic toxicity; Antidote
Hot as a hare - hyperpyrexia, Dry as a Bone - decreased secretion, Red as a Beet - cutaneous flushing, Blind as a Bat - cycloplegia/mydriasis, Mad as a Hatter - disorientation, Bloated as a Toad - constipation/urinary retention; Tachycardia, decreased or absent bowel sounds; Physostigmine
Tx bradycardia due to Beta-blocker overdose
IV fluid bolus; Atropine raise heart rate, GI decontamination w/ activated charcoal, gastric lavage if within 1 hr or hypotension, whole bowel irrigation if extended release pill; If bp and HR unresponsive, successive approach: Atropine (0.5-1 mg), Glucagon IV bolus, repeat, Calcium chloride (1 amp - same thing as 3 amp Calcium gluconate), Insulin & glucose (monitor, titrate for euglycemia), NE (vasopressor), temporary transvenous pacing, intra-aortic balloon, cardiopulmonary bypass (or transthoracic pacemaker)
Tachycardia, HTN, flushing, tachypnea, obtundation, resulting in coma & death; Almond-scented breath; Late - bradycardia, bradyapena, hepatic necrosis, delayed onset parkinsonism
Cyanide toxicity (note: basal ganglia sensitive to cyanide, hence parkinsonism)
Cyanide toxicity tx
Mouth to mouth contraindicated in cyanide ingestion; One dose of activated charcoal, if oral ingestion; Nitrates (induce methemoglobinemia, lethal in children and patients anemic, reversed w/ methylene blue, works well with sodium thiosulfate), hydroxocoblamin (directly binds to cyanide, also excreted in urine, works well with sodium thiosulfate, preferred over nitrates), thiosulfate (increases renal secretion)
Digoxin toxicity s/sx
Non-specific sx: fatigue, blurred vision, changes in color (or yellow) vision, n/v, abdominal pain, diarrhea, confusion, delerium; EKG - prolonged PR, scooping ST segments; bradycardia (also accelerated junctional rhythm and/or bidirectional ventricular tachycardia), hyperkalemia (increases severity), elevated serum Digoxin levels
Tx digoxin toxicity
Activated charcaol, repeated dose; Dig antibody fragements (Fab fragments) if one of following present - hemodynamic instability,life threatening arrhythmias or bradycarida, severe hypothermia, plasma potassium > 5, plasma dig > 10, ingestion of dig > 10 mg in adults or > 4 mg in children, Dig toxin rhythm; Tx hyperkalemia only if causing EKG disturbances (avoid calcium); ACLS medications as needed, except calcium
Tx ingested ethanol or ethylene glycol
ABC, NG Tube (gastric aspiration within last 60 min), Sodium bicarbonate (correct acidosis - recall MUDPILES, elevated anion gap metabolic acidosis), Fomepizole/Ethanol (inhibit alcohol dehydrogenase); Fomepizole (preferred drug, IV load then q 12 hr) or Ethanol IV drip (if no Fomepizole); Dialysis (if metabolic acidosis or evidence of end organ damage); Folic acid, thiamine, pyridoxine (oxidize elimination pathways, eliminate more quickly)
Tinnitus, hyperthermia, respiratory alkalosis then metabolic acidosis, n/v, dehydration, AMS
ASA overdose
Not for step 2 - Tx elevated INR from excessive warfarin ingestion
see 1:10:00 to fill in card after step 2 ck
Schizophrenia pt come to ER for drinking alkali plumber fluid
ABC, emergent surgery if signs of perforation/mediastinitis/peritonitis, esophagectomy; Do not give neutralizing agent, NG Tube, or emetic; if asymptomatic; if endoscopy mild or no injury, f/u… if grade 1-2, monitor… grade 3+, npo for 24 h, ng tube feeds, food, minimal one week observation for signs of perforation, icu care may be needed, ppi for stress ulcer prevention, esophageal dilation may be necessary (prevent strictures), surveillance EGD beginning at 15-20 years after ingestion (screen for squamous cell esophageal cancer)
s/sx organophosphate poisoning
DUMBELSS, diarrhea, urination, miosis, bronchospasm, excitation of skeletal muscle, lacrimation, sweating/salivation
Excessive iron consumption in kid
GI phase - melena, n/v, etc.; Latency (6-24 hr after) - monitor to see if mild or resolution; Late phase (6-72 hr) - shock, multisystem organ failure, outcomes poor; Liver necrosis (12-96 hr), bowel obstruction (2-8 wk after)
Arsenic reversal
Dimercaprol, Succimer, Penicillamine
Copper toxicity reversal
Penicillamine
TPA, Streptokinase reversal
Aminocaproic acid
Theophylline toxicity s/sx and risks
Low therapeutic index (low dose of 25 still worrisome); seizures, hypothermia, cardiac tachyarrhythmias; elderly, hypoalbuminemia, & cardiac issues more susceptible
Tx stable, asymptomatic VTach
Amiodarone, Lidocaine, or Procainamide
Tx Vfib/Pulseless Vtach
360 J, CPR 2 min, 360 J, Continue CPR - Epi (for 1st dose only, vasopressin can be used instead), 360 J, Repeat Epi every 3-5 min, Consider antiarrhythmis amiodarone/lidocaine
Tx PEA
CPR, Epi q 3-5 min, Atropine 1 mg q 3-5 min x 3 (alternate Epi & Atropine q 2 min, after 3 dose of Atropin, continue w/ Epi only q 3-5 min)
H’s & T’s of PEA
Hypovolemia, Hypoxia, Hyperkalemia, Hypokalemia, Hypothermia, Hydrogen ions (acidosis), Tamponade, Tension pneumo, Thrombosis (MI or PE), Tablets/Toxins (drugs)
Tx SVT
Vagal maneuver (i.e., carotid massage), Adenosine, Ventricular rate control w/ digoxin/CCB/beta blocker/combination, Electrocardioversion
Initial tx of initial Afib w/ rapid ventricular rate of unknown duration
Rate control w/ digoxin/CCB/beta blocker/combo; Anticoagulate w/ Heparin… then Warfarin; Not Electrocardioversion (risk stroke)
