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Emergency and Toxicology Flashcards

1
Q

What is the next step in management for a pt who presents to ED with acute change in mental status and decreased RR of unclear etiology?

A

Administer:
Naloxone
Thiamine
Dextrose

(Remember, ALWAYS give Thiamine BEFORE Dextrose)

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2
Q

When should Gastric emptying be used in a pt with acute mental status changes subsequent to possible drug overdose?

A

ONLY within the FIRST HOUR of the overdose!!

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3
Q

When should Ipecac be used in possible overdose situations?

A

Never in children
Never when there is altered mental status (pt will aspirate)

Don’t Use it!!!

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4
Q

When can Intubation and lavage be used in possible overdose?

A

Only within the first 1-2 hours following overdose after a trial of Naloxone,Thiamine, and dextrose have failed to correct symptoms

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5
Q

What is an absolute contraindication to Gastric Emptying for overdose/Intoxication?

A

When acids/alkalis (caustic substances) ingested

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6
Q

When should Charcoal be given to a pt with possible intoxication/overdose?

A

When it is unclear what to do–>charcoal is a safe option
It can be given at anytime to any such pt
It has no negative effects

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7
Q

What are the steps in management for a pt who presents with an Overdose?

A

1) Antidote (known toxin) or Naloxone,Thiamine, Dextrose
2) Toxicology Screen
3) Charcoal
4) Labs: CBC, Chemistry, Urinalysis
5) Order Psychiatric Consultation (if suicide attempt)
6) Oxygen (anyone w/ dyspnea and /or CO poisoning)

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8
Q

What is the antidote for ACETAMINOPHEN intoxication?

A

N-acetyl Cysteine (NAC)

Note: Always GIVE FIRST, then get levels if unknown amount

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9
Q

What is the antidote for ASPIRIN intoxication?

A

Bicarbonate (alkalinize urine, aspirin will be excreted)

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10
Q

What is the antidote for BENZODIAZEPINE intoxication?

A

Let pt sleep.

DO NOT GIVE Flumazenil (can induce withdrawal –> seizure)

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11
Q

What is the antidote for CARBON MONOXIDE intoxication?

A

100% Oxygen (Hyperbaric if needed)

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12
Q

What is the antidote for DIGOXIN intoxication?

A

Digoxin-binding Ab’s (DigiFAB/Digibind)

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13
Q

What is the antidote for ETHYLENE GLYCOL intoxication?

A

Fomepazole or Ethanol

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14
Q

What is the antidote for METHANOL intoxication?

A

Fomepazole or Ethanol

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15
Q

What is the antidote for METHEMAGLOBINEMIA?

A

Methylene Blue

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16
Q

What is the antidote for NEUROLEPTIC MALIGNANT SYNDROME?

A

Bromocriptine or Dantrolene

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17
Q

What is the antidote for OPIATES intoxication?

A

Naloxone

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18
Q

What is the antidote for ORGANOPHOSPHATE intoxication?

A

Atropine and Pralidoxime (cannot give atropine alone)

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19
Q

What is the antidote for TRICYCLIC ANTIDEPRESSANT (TCA) intoxication?

A

Bicarbonate (cardioprotective) (prevents QT prolongation)

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20
Q

What is the presentation of a pt with Acetaminophen intoxication?

A

Nausea/Vomiting within first 24 hrs; then it resolves

Hepatic Failure at 48-72 hrs post intoxication

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21
Q

When should NAC be given to a pt with Acetominophen overdose?

A

Best within first 24 hrs, but give to any pt with acetominophen overdose of a toxic amount

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22
Q

What can be given with NAC to treat Acetaminophen toxicity?

A

Charcoal

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23
Q

If pt with acetaminophen toxicity is vomiting, what should be used as an antidote?

A

IV NAC

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24
Q

What is the order of treatment/workup for a pt presenting in ED with Acetaminophen ingestion?

A

1)Give NAC (if vomiting–> use IV) THEN…

2)If ingested amount unknown,
-order Acetaminophen bld level (to determine if there
will be toxicity)

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25
What amount of Acetaminophen are considered toxic and fatal?
``` 10g = Toxic 15g = Fatal ``` These will be lower for those with underlying liver disease or alcohol abuse
26
What are the physiologic effects of Apirin toxicity? (10)
Respiratory Alkalosis (Brainstem-increased resp drive) ARDS (Direct Lung Toxicity) High Anion Gap Metabolic Acidosis (Inhibition of Kreb Cycle Enzymes, Uncouples Ox Phos, increased catabolic activity--> generating acidic byproducts) Elevated PT (Inhibition of Vit-K dep Clotting Factors 2,7,9,10 c/s) Renal Insufficiency (Direct tubule toxicity) Fever (increased O2 utilization/increased Glc demand--> glycogenolysis and other catabolic processes) Tinnitus (Direct CNS toxicity, early sign) Altered mental status (confusion, seizure, coma d/t direct CNS toxicity, electrolyte losses, decreased O2 and glc availibility) Dehydration (increased urinary, GI, and insensible fluid losses) Nausea/Vomiiting (Direct CNS/GI toxicity)
27
What should be ordered in the workup of Aspirin (Salicylate) toxicity?
``` CBC Chemistry panel ABG PT/PTT/INR Salicylate (ASA) Level ```
28
What is the order of treatment for Aspirin (Salicylate) overdose?
Bicarbonate (3 amps) w/ D5Water (glucose in needed) Charcoal(block GI absorption) Dialysis (if severe) (Note: Alkalinization of Urine aids in excretion of ASA)
29
What is an early and specific sign of Aspirin toxicity?
Tinnitus (direct CNS toxicity)
30
What is the most common cause of death from fires?
Carbon Monoxide (CO) Poisoning
31
What is the mechanism of CO poisoning?
CO has very high affinity for Hb--> does not allow max O2 carrying capacity AND... When 1 molecule of CO binds Hb-->increased the affinity of other binding sites for O2--> decreased O2 delivery to tissues
32
What are the features associated with a pt with CO poisoning? (5)
``` Fatigue Headache/Lightheadedness Dyspnea/SOB Disorientation Metabolic Acidosis (severe cases, d/t tissue hypoxia) ```
33
Under what conditions/history should CO poisoning be suspected?(3)
Pt involved in Fire Indoor Grilling Home-bound (from snowstorm) w/wood-burning stove; symptomatic relief when outside of home
34
What is the workup/treatment for CO poisoning?
Call ambulance if in field If at hospital--> immediately give -100% oxygen (esp to all in fires until CO levels known) -Check CO levels
35
What is the most common presentation for Digoxin Toxicity?
GI disturbances (N/V, abdominal pain, diarrhea)
36
Besides GI symptoms, what are other findings associated with Digoxin toxicity? (5)
Vision changes (blurry/Yellow Halos) Arrythmia (Heart Block, Paroxysmal Atrial Tachycardia w/ block, PR prolongation, or any other abnormal rhythm) Encephalopathy Hyperkalemia
37
What metabolic abnormality can precipitate Digoxin toxicity?
Hypokalemia (facilitates Digoxin binding to N/K ATPase)
38
What is the treatment for Digoxin Toxicity?
Severe Cases : DigiFAB/Digibind (Digoxin-binding Ab's) Always check EKG, Electrolytes (K+), {Note: severe cases are those involving CNS/cardiac abnormalities]
39
What are the common features seen in both Ethylene Glycol and Methanol poisoning?
Ingestion/Intoxication | High Anion Gap Metabolic Acidosis
40
What are specific findings associated with Ethylene Glycol Poisoning?
Renal Insufficiency (Tubule toxicity) Sones (oxalic Acid + calcium) Hypocalcemia (oxalic acid is a metabolite of EG-->Ca binding--> decreased calcium)
41
What are specific findings associated with Methanol poisoning?
``` Visual disturbances --> Blindness Retinal Hyperemia (d/t Formic acid formation) ```
42
What is the treatment for both Ethylene Glycol and Methanol Poisoning? (2)
Ethanol or Fomepizole | Dialysis (to remove the alcohols before they are metabolized; metabolites are toxic)
43
What are some typical exam findings associated with METHEMOGLOBINEMIA?
``` Cyanosis SOB Dizziness Headache Confusion Seizure ```
44
What is the underlying mechanism for Methemoglominemia toxicity?
Hb is locked into a Ferric (Fe3+) state-does not facilitate O2 binding, but when it does, it does not unload it efficiently
45
What is the workup for Methemoglobinemia?
ABG- Normal PaO2 w/ Chocolate-brown blood | Methemoglobin Level
46
What is the treatment for Methemoglominemia?
``` 100% oxygen Methylene Blue (to restore reduce Hb to normal Ferrous(2+) state) ```
47
What medications can be associated with Methemoglobinemia?
Nitrates Anesthetics (-caine's) Dapsone Other Oxidants
48
What condition should be susprected in a pt who is Cyanotic but has a normal PaO2?
Methemoglobinemia
49
What are features common of all heat/overheating disorders?
Rhabdomyolysis | +/-Confusion, Seizure, Arrhythmia
50
What tests are involved in the workup of Neuroleptic Malignant Syndrome (NMS)?
No specific tests but should check: - CPK, K+ (can be high) - Physical Exam: muscle rigirdity
51
What history finding will be present in all cases of NMS?
Ingestion of Antipsychotic (neuroleptic) medications (ex: Phenothiazines)
52
What is the treatment for NMS?
Dopamine Agonists: -Bromocriptine -Carbergoline Dantrolene (muscle relaxant)
53
What is a common component of pt history associated with Malignant Hyperthermia?
Anesthesia use (inhaled, ex halothane)
54
What is the treatment for Malignant Hyperthermia?
Dantrolene
55
What features of history are usually present in a pt that should be suspected of Heat Stroke?
High Ambient Temp and Dehydration/Physical Exertion
56
What are some typical findings associated with Heat Stroke?
``` Dry skin Fever Altered Mental Status -Confusion -Seizures Hyperkalemia Arrhythmias ``` (same with NMS and MH)
57
What is the treatment for Heat Stroke?
Physical Removal of Heat from pt Body: - Ice bath/pack - Spraying pt with water and fanning in AC'd room [Note: never inject iced saline--> can cause cardiac arrest]
58
What findings can be associated with heat Exhaustion to help distinguish it from Heat stroke?
Excessive Sweating | Nausea/Vomiting
59
What is the treatment for Heat Exhaustion?
Normal IV Saline | Remove pt from hot environment to cool one
60
What is the cause of death associated with Opiate intoxication?
Respiratory Depression
61
What occupation or exposure should raise suspicion for Organophosphate intoxication?
Crop dusters/Insecticide exposure | Nerve-gas exposure
62
What findings are associated with organophosphate intoxication?
Whee SLUDGE: ``` Wheezing Salivation Lacrimation Urination Defecation/Diaphoresis GI distress Emesis ```
63
What treatment is used for Organophosphate intoxication?
1) Wear protective Apparel 2) Remove pt clothing(absorbed through skin) 3) Atropine (anticholinergic) 4) Pralidoxime (most effective--> rescues Achesterase) 5) Wash chemical off pt (absorbed through skin)
64
What are the main causes of death associated with TCA overdose?
Seizure | Arrhythmia ( Ventricular-Wide QRS/ Torsade ; Long QT)
65
What is the first step in management for a pt presenting with suspicion of TCA overdose?
EKG (check for arrhythmias)
66
What is the next step in management for a pt with a TCA overdose whose EKG shows wide QRS or any arrhythmia?
Bicarbonate administration | Transfer to ICU
67
When should Bicarbonate be given to a pt with TCA overdose?
Only with EKG confirmed arrythmia!! | (Always check EKG FIRST, then proceed to rest of management)
68
What are some features associated with TCA overdose?
Anticholinergic Phenom: - Dry mouth/skin - Dilated Pupils - Constipation - Urinary Retention
69
What features are associated with a bite from a Black Widow Spider?
Abdominal pain, rigidity w/o tenderness on exam (looks like perforation but no tenderness) Hypocalcemia
70
What is the treatment for a black wiow spider bite?
Antivenin
71
What features are associated with a Brown recluse spider bite?
Local Necrosis Bullae Eschar
72
What is the treatment for a Brown recluse spider bite?
Wound Debridement | Steroids/Dapsone may be useful in some cases
73
What is the most common cause of death from fires?
CO poisoning
74
What are the three initial steps in management for a burn victim?
1) Give 100% Oxygen and check CO levels 2) Check Airway-determine if intubation needed 3) Give Fluids
75
What are the indications for intubating a burn pt?
Hoarsness Wheezing Stridor Burns within nose or mouth
76
When should fluid administration follow Oxygen administration in s burn pt?
Only AFTER airway is assessed and no intubation indicated
77
What are the guidelines for fluid adminstration in a burn pt?
Lactated Ringers or Normal Saline: | (4mL ) x (%w/2nd or 3rd degree burn) x (wt in kgs)
78
What is the most common cause of death in HypOthermic pts?
Arrhythmias
79
What is the first step in management for a pt presenting with Hypothermia?
EKG
80
What EKG finding is specific for Hypothermia?
J-waves of Osbourne (look like ST elevation)
81
Who is most likelt to present with hypothermia?
Alcoholic who fell asleep outside in winter
82
What is the typical physical exam/history finding for a pt with Acute Angle Closure Glaucoma
Sudden onset Eye pain with Redness, Hard on Palpation Fixed Midpoint pupil Hazy Cornea
83
What are the best initial steps in management/treatment for a pt with Acute Angle Closure Glaucoma?
1) Tonometry Exam then | 2) Give Pilocarpine Drops (to constrict pupil-Ach agonist)
84
In addition to the best initial treatment, what other medications are used to treat/manage acute angle closure glaucoma?
Mannitol (osmotic diuresis) Acetzolamide (decrease Aqueous humor production) Prostaglandin Analog (Latanaprost, Travaprost B-Blocker (Timolol) Apha Agonist (Apraclonidine)
85
What is the most common complaint associated with Retinal detachment?
Sudden loss of vision "like curtain coming down over eye"
86
What is the best initial steps in managing Retinal Detachment?
Dilated Eye/Retinal Exam | Order Ophthalmology Consultation
87
What are the treatment options for Retinal Detachment?
1) Tilt pt Head Bk 2) Reattach retina via - Surgery - Cryotherapy - Expansile Gas Injection 3)If these fail, place band around eye-->bring retinal close to sclera
88
What are 4 common conditions associated with Red Eye?
Glaucoma (Acute Angle Closure) Conjunctivitis Uveitis Corneal Abrasion
89
What is the next step in management for a pt presenting with BILATERAL watery, non purulent ocular discharge, redness, and itching?
Dx based on clinical presentation | -Viral conjunctivitis or Allergic conjunctivitis
90
What is the next step in management for a pt presenting with UNILATERAL purulent ocular discharge with redness and lid crusting and stuck together?
Dx based on clinical presetnation: Bacterial Conjunctivitis
91
What is the treatment for conjunctivitis?
Bacterial: topical Antibiotics, Warm Compresses
92
What is the most likely diagnosis when a pt presents with PHOTOPHOBIA, eye pain w/o discharge, redness, floaters, +/- blurry vision?
Uveitis
93
What is the next step in dx'ing Uveitis?
SLit lamp Exam
94
What treatment if given for Uveitis?
Steroids (anti-inflammatory)
95
What is the most likely dx in a pt presenting with red watery eye and a h/o eye trauma, esp from contact lenses, or foreign body getting into eye?
Corneal Abrasion
96
What is the next step in management for a pt presenting with a possible corneal abrasion?
Eye exam using Fluoroscein Stain
97
What is the treatment for corneal abrasion?
No specific therapy | Do not patch abrasions d/t contacts

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