Emergency Flashcards
Pulsus paradoxus
Abnormally large drop (>1mmHg) in SBP on inspiration
Cardiac tamponade sign
Beck’s triad
Hypotension, distended neck veins, muffled heart sounds
For cardiac tam pomade
Kussmaul sign
Rise in JVP on inspiration
Sign of cardiac tamponade
Types of distributive shock
Septic, SIRS/inflammatory, neurogenic
Indications for dialysis
Acidosis Electrolytes (inc K) Intoxication (ASA, methanol, ethylene glycol) Overload (fluid) Uremia
Anion gap
Measured - (Na - (Cl +HCO))
Osmolar gap
Measured - (2Na + glucose + BUN + (1.25*EtOH))
Normal < 10
Causes of anion gap
Methanol Uremia DKA Paraldehyde Iron, INH, ibuprofen Lactate Ethylene glycol Salicylates
Toxidrome for anticholinergics?
Clinical findings include hypotension or hypertension, tachycardia, hypoactive or absent bowel sounds, urinary retention, flushed skin, hyperthermia, dry skin and mucus membranes, mydriasis, confusion, agitation, disorientation, and auditory and visual hallucinations.
Mad as a hatter, etc.
Ex. scopolamine, atropine
Treatment for anticholinergic toxicity?
Treatment is primarily supportive. The goal is to prevent life-threatening complications, which include status epilepticus, hyperthermia, cardiovascular collapse, and rhabdomyolysis.
The patient should be placed on a cardiac monitor and intravenous or intraosseus access secured. Activated charcoal may decrease drug absorption, even beyond 1 hour of ingestion. Temperature monitoring is essential. Hyperthermia is treated conventionally. Hypertension usually does not require intervention, but should be treated conventionally as necessary. Standard antiarrhythmics are usually effective, but avoid class IA medications (eg, procainamide). Treat dysrhythmias, widened QRS complexes, and hypotension from sodium blocking agents (eg, cyclic antidepressants) with IV sodium bicarbonate 1 mEq/kg. Treat agitation with benzodiazepines (lorazepam 2 to 4 milligrams IV or 0.1 milligram/kilogram). Phenothiazines should be avoided. Treat seizures with benzodiazepines (lorazepam 2 milligrams IV). Physostigmine treatment is controversial. It is indicated if conventional therapy fails to control seizures, agitation, unstable dysrhythmias, coma with respiratory depression, malignant hypertension, or hypotension. The initial dose is 0.5 to 2 milligrams IV (0.02 milligram/kilogram in children, maximum dose 0.5 milligram/dose), slowly administered over 5 min. When effective, a significant decrease in agitation may be apparent within 15 to 20 min. Physostigmine may worsen cyclic antidepressant toxicity and lead to bradycardia and asystole. It is contraindicated in patients with cardiovascular or peripheral vascular disease, bronchospasm, intestinal or bladder obstruction, cardiac conduction disturbances, and suspected concomitant sodium channel antagonist poisoning. The patient should be observed for cholinergic excess. Patients with mild anticholinergic toxicity can be discharged after 6 hours of observation if their symptoms have resolved. More symptomatic patients should be admitted for 24 hours of observation. Patients who receive physostigmine usually require, at least, a 24-hour admission.
Clinical features of cyclic antidepressant OD?
Cyclic antidepressants inhibit reuptake of norepinephrine and serotonin and antagonize postsynaptic serotonin receptors. They can produce severe toxicity in overdose.
Clinical Features
Toxicity may present with altered mental status, seizures, cardiac conduction or rhythm disturbances, hypotension, respiratory depression, and, in severe cases, coma.
Diagnosis
ECG changes include sinus tachycardia; right axis deviation of the terminal 40 milliseconds; PR, QRS, and QT interval prolongation; right bundle-branch block; A-V blocks; and the Brugada pattern.
Management of cyclic antidepressant OD?
Care is primarily supportive.
Obtain IV access and initiate cardiac rhythm and ECG monitoring. Patients should receive 1 gram/kilogram of activated charcoal PO. This may be preceded by gastric lavage in patients presenting < 1 hour after a large ingestion. Hypotension is treated with isotonic crystalloids. If no response, administer sodium bicarbonate as an IV bolus of 1 to 2 mEq/kg, repeated until the patient improves or until blood pH is 7.50 to 7.55. A continuous IV infusion (150 mEq added to 1 L of 5% dextrose in water) may be used at a rate of 2 to 3 mL/kg/h. Norepinephrine is indicated if hypotension persists. Treat conduction disturbances and ventricular dysrhythmias with sodium bicarbonate . Synchronized cardioversion may be indicated for unstable patients. Treat torsades de pointes with 2 grams of IV magnesium sulfate . Control agitation with benzodiazepines. Treat seizures with benzodiazepines. Phenobarbital , starting at 15 milligrams/kilogram IV, may be required for refractory seizures. Patients who remain asymptomatic after 6 hours do not need admission for toxicologic reasons. Admit symptomatic patients to a monitored bed or intensive care unit (ICU).
Features and management of trazadone OD?
Clinical Features
Symptoms of toxicity include central nervous system depression, ataxia, dizziness, seizures, orthostatic hypotension, vomiting, and abdominal pain. ECG abnormalities include QT interval prolongation, sinus bradycardia and tachycardia, and torsades de pointes.
Emergency Department Care and Disposition
Supportive care is generally sufficient in isolated overdoses.
Initiate cardiac rhythm monitoring and obtain a 12-lead ECG. Single-dose activated charcoal is recommended. Gastric lavage followed by activated charcoal may be beneficial for trazodone ingestions >2 grams if early after ingestion. Treat hypotension with isotonic IV fluids, followed by norepinephrine . Treat torsades de pointes with IV magnesium sulfate . Discharge patients who remain asymptomatic for at least 6 hours, with psychiatric evaluation as indicated. Admit those with neurologic and/or cardiac symptoms for >6 hours after ingestion to a monitored bed.
Features and management of Buproprion OD?
Toxicity manifests as agitation, dizziness, tremor, vomiting, drowsiness, and tachycardia. Seizures are more common than with other atypical antidepressants. ECG changes include sinus tachycardia, QRS interval widening, and QT interval prolongation.
Emergency Department Care and Disposition
Seizures should be anticipated. Cardiotoxicity is unlikely in isolated overdoses.
Start a peripheral IV line and initiate cardiac rhythm monitoring. GI decontamination is recommended if done within 1 hour of ingestion. Consider whole-bowel irrigation in overdoses of sustained-release products. Treat seizures with benzodiazepines, followed by phenobarbital . Observe asymptomatic patients for 8 hours. Monitor patients ingesting >450 milligrams of sustained-release bupropion for up to 24 hours. Admit those with seizures, persistent tachycardia, or lethargy.
Features and management of mirtazapine OD?
Toxicity causes sedation, confusion, sinus tachycardia, and hypertension. Coma and respiratory depression are seen in severe cases or with coingestion of other sedatives.
Emergency Department Care and Disposition
Isolated overdoses can generally be managed with supportive care. Single-dose activated charcoal is recommended for GI decontamination. Admit symptomatic patients to a monitored bed. Discharge asymptomatic patients after 6 hours.
