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RACP paeds Qld Group > Emergency Medicine > Flashcards

Emergency Medicine Flashcards

1
Q

3 Cs of TCA poisoning

A

Convulsions
Coma
Cardiac (widened QRS –>VT)
**as TCA is a sodium channel blocker–> channelopathy –> wide QRS

**essentially leads to anticholinergic/seritonergic syndrome

Treat with 2C’s: BI -Carbonate if QRS widened or ventricular arrythmia
Can give activted charcoal if severe but need to intubate first
after intubation, hyperventilate to optimise pH to 7.5 (alkalise)

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2
Q

Anticholinergic antidote

A

Normally just supportive - treat symptoms
Physostigmine- contravertial

Sodium bicarbonate if TCA

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3
Q

Anticholinergic syndrome - triggering agents

A

Antihistamines
Anti tussives
Dextromethopha, diphenhydramine
Antipsychotics
Anti convulsants- carbamazepine
Anti emetics - hyoscine
Other: benztropine glycopyrrolate, oxybutynin

“travelcalm” - antihistamine + hysocine bromide

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4
Q

Anticholinergic syndrome presentation

A

fever
delirium
confusion
dilated pupils/mydriasis
dry flushed skin and mouth
constipation, reduced bowel sounds
urinary reterntion
hypertension
picking

Severe:
coma
HTN
QRS widening and increased QT
rhabdomyolysis
seizures

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5
Q

B blocker antidote

A

glucagon
or
high dose insulin with glucose infusion

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6
Q

benzodiazapine antidote

A

flumazenil (if iatrogenic, as can cause seizures in withdrawal)

usually only need supportive care

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7
Q

beta blocker overdose presentation

A

bradycardia
altered mental state - coma
hypotension
ventricular arrythmias –> VT
hypoglycemia

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8
Q

brain imaging when CNS tumor suspected

A

Persistent headache in the following settings: wakes a child from sleep; occurs upon waking; in any child less than four years of age; associated with disorientation or confusion.
Persistent vomiting upon waking.
Visual findings including papilloedema, optic atrophy, new onset nystagmus, reduced acuity not due to refractive error, visual field reduction, proptosis, and new onset paralytic (non-comitant) squint.
Motor findings including regression in motor skills, focal motor weakness, abnormal gait and/or coordination, bell’s palsy with no improvement over four weeks, and swallowing difficulties without an identifiable local cause

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9
Q

how do you maximise urinary excretion of aspirin

A

urinary alkalinisaiton with sodium bicarbonate

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10
Q

Organophosphate ingestion

A

= cholinergic syndrome
KILLER Bs
Bronchospasm
Bronchorroas
Bradycardia
Pinpoint pupils

SLUDGE
Salivation
Lacrimation, lethargy
Urination
Diarrhoea + abdo cramping
Emesis

think WATER FROM EVERYWHERE

+ agitation, anxiety, seiixures, coma, flaccid paralysis
Pinpoint pupils

Rx: atropine

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11
Q

which toxidromes have pinpoint pupils

A

cholinergic syndrome
opioids- morphine, fentanyl
alcohol
BZDs

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12
Q

which toxidromes have hyperthermia

A

anticholinergic (hot as a hare)
sympathomimetic
seritonin syndrome

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13
Q

main features serotonin syndrome

A

Cognitive effects: delirium, headache, agitation, hypomania, mental confusion, hallucinations, coma
Autonomic effects: shivering, sweating, hyperthermia, hypertension, tachycardia, nausea, diarrhoea.
Somatic effects: myoclonus (muscle twitching), hyperreflexia (manifested by clonus), tremor.

DILATED PUPILS

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14
Q

which are the “single pill can kill” drugs

A

Emphetamines (ecstacy)
Ca channel blockers
Beta blockers
Opioids
Sulfonylureas
Theophylline
TCA
Chloroquine

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15
Q

when can activated charcoal be used for ingestions?

A

<120 mins since ingestion
Chloroquine
Ca channel blocker
carbamazepine
cochicine
beta blockers
flecanide
salicilates

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16
Q

Contraindications for activated charcoal

A

Alt mental status- high risk of aspiration (would need to intubate first)
Acid/alkali
GI perforation
Ethanol
Hydrocarbons
Any metals, potassium , iron, lead etc
>1 hour post ingestion

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17
Q

when is whole bowel irrigation used

A

only for slow release enteric coated tablets
can be used for iron when desferroxamine has not been effective

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18
Q

organophosphate antidote

A

atropine (anticholintergic)

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19
Q

iron antidote

A

desferoxamine

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20
Q

lead antidote

A

EDTA

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21
Q

methonol or ethylene glycol antidote

A

ethanol

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22
Q

BZD antidote

A

flumazenil

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23
Q

MoA anticholinergic syndrome

A

Anticholinergic syndrome results from competitive antagonism of acetylcholine at central and peripheral muscarinic receptors. Central inhibition leads to an agitated (hyperactive) delirium - typically including confusion, restlessness and picking at imaginary objects - which characterises this toxidrome.

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24
Q

how do you achieve cooling in overdose such as ecstasy where there is hyperthermia

A

Removal of clothing
Ice packs to nape of neck, armpits
Fans
Gastric lavage
Cooled IV fluids

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25
Q

ethylene glycol

A

Found in Anti-Freeze/Carpet fabric cleaners
Toxic levels: 100mls - Adults, 20mls - Child
3 stages - CNS depression—> CVS/Resp depression —> Renal failure
High anion gap metabolic Acidosis —> Renal Failure
24-36hrs - to be fatal
Levels able to be measured

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26
Q

Neuroleptic Malignant syndrome

A

life threatening neorological emerency associated with use of antipsychotic agents

Increased body temperature >38°C
Confusion, delirium or altered consciousness
Fever
Rigidity
Dysautonomia
–> rhabdo, hyperkalemia, AKI, seizures

both typical and atypical antipsychotics

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27
Q

Carbon monoxide poisoning

A

CO preferentially binds to haemoglobin (200x higher affinity for Hb compared to O2) reducing its oxygen-binding capacity, it shifts the oxygen dissociation curve to the left thus inhibiting the release of bound oxygen in the periphery and it acts as a direct cellular toxin by impairing aerobic metabolism.

myalgia, headache, weakness, clumsiness, blurry vision, flu like illness-> seizure, coma, cardiac arrest
COhb >10-40%

Rx:100% high flow O2 or hyperbaric O2 to replace carboxyHb and supersaturate blood with O2
D: may cause Parkinsonism
**Displaces O2 from haemoglobin as CO has much higher affinity for Hb than O2

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28
Q

Methaemoglobinaemia

A

Methaemoglobinaemia is the state of excessive methaemoglobin in the blood

methaemoglobin is an altered state of Hb where ferrous ions (Fe2+) of haem are oxidised to the ferric state (Fe3+) and rendered unable to bind O2
normal level is < 1.5%

Can occur with ingestion of cold packs or nitrites in meat
can also be congenital

Rx: high flow 100% O2. methylene blue.

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29
Q

Lead poisoning

A

non specific signs from chronic ingesiton
Fanconi syndrome, microcytic anemia, reduced bone and muscle growth, behavior problems, lower IQ
Lead lines on Xray

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30
Q

calcium channel blocker antidote

A

calcium gluconate
Insulin/glucose
intralipid

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31
Q

calcium channel blocker o/d presentation

A

bradycardia
hypotension
shock

32
Q

complications amphetamine overdose

A

DILATED PUPILS

Severe hyperthermia- requiring cooling
Rhabdo
Seizures
Intracranial haemorrhage
Hyponatremia
Cerebral oedema

33
Q

cholinergic overdose

A

WET- secretions everywhere

Confusion, coma
Pinpoint pupils
Wet- salivation, lacrimation,urination, diarrhoea, vomiting
Killer Bs- bronchorroea, bradycardia, bronchospasm
Hypotension –> cardiovascular collapse

Examples- organophosphates, nerve agents, physostigmine, poisonous mushrooms

Antidote: ATROPINE
Pralidoxime binds organophosphate

34
Q

cyanide antidote

A

hydroxocobalamin
dicobalt edetate
sodium thiosulphate

35
Q

difference between serotonin syndrome and neuroleptic malignant syndrome

A

Serotonin- abrupt onset, resolves quickly, increased reflexes, myoclonus and tremor, dilated pupils

neuroleptic malignant - gradual onset, prolonged course, muscle rigidity, hyporeflexic, normal pupils

36
Q

digoxin antidote

A

digoxin immune Fab- Digibind

37
Q

EBV symptoms

A

fever
malaise
cervical lymphadenopathy (posterior)
headache
pharyngitis/tonsilitis with exudate
herpangina
nausea/vomiting/anorexia
splenomegaly (hepatomegaly uncommon)
Ix: lymphocytosis, deranged LFTs

38
Q

ethylene glycol antidote

A

ethanol
pyridoxine

39
Q

eucalyptus oil poisoning

A

Onset: Within 30 mins to 4 hours post ingestion
Duration of symptoms: usually resolve within 24 hours
Dose related toxicity
Small ingestions of pure oil can lead to severe symptoms. A dose of 2-3 mL can induce mild CNS depression with drowsiness and/or dizziness and ataxia. A dose of ≥5 mL can induce significant CNS depression with coma

miosis/mydriasis
myoclonuc
CNS depression- drowsiness, dizziness, ataxia, seizures
tachycardia
hypotension
respoiratory depression, bronchospasm, apnoea, aspiration pneumonitis

nausea/vominting, epigastric pain, diarrhoea

Rx: supportive care

40
Q

Hallucinagen O/D (eg LSD)

A

Hyperthermia
Tachycardia
Hypertension
Hallucinations
Agitation
Dilated pupils
Nystamus

41
Q

Iron overdose

A

<20 mg/kg: asymptomatic
20-40 mg/kg: GI symptoms only. Symptoms usually last <6hrs
40-60 mg/kg: GI symptoms, systemic toxicity not expected. Symptoms usually last <8hrs
60-120 mg/kg: potential for systemic toxicity
>120 mg/kg potentially lethal
Presentation
Initial GI symptoms
Quiescent/latent period 6-24 hrs with improvement in GIT symptoms
Cardiogenic shock and acidosis - multi system organ failure, coma
Hepatic necrosis –> acute liver failure
Bowel obstriction after 2-8 weeks

Ix:
AXR if tablet ingestion
FBE: leukocytosis
UEC,LFT
VBG- high anion gap metabolic acidosis, hypoglycemia
Serum iron immediately and at 4 hours
Coags- coagulopathy secondary to liver
injury

Management
Antidote- desferrioxamine
WBI if desferrioxamine doesnt work

42
Q

isoniazid antidote

A

pyridoxine

43
Q

local anaesthetic antidote

A

intralipid

44
Q

local anaesthetic o/d management

A

sodium bicarbonate if ventricular dysrythmias 2’ sodium channel blockade
intralipid 20% - severe cardiovascular toxicity
methylene blue for methaemoglobinaemia

45
Q

brown snake bite effects

A

Coagulopathy
DIC
Neurotoxicity- rare, nil myotoxicity
abnormal INR, high aPTT, fibrinogen very low, D-dimer high

46
Q

most common effect tiger snake bite

A

Consumptive coagulopathy
Neurotoxicity - 30%
Myotoxicity- 20%

47
Q

most common effect of ethanol in young child

A

ypoglycemia

Alcohol poisoning – drowsiness, dysarthria, ataxic and hypoglycemia.
Alcohol inhibits gluconeogenesis but plasma glucose can usually be maintained from glycogen breakdown

48
Q

neuroleptic malignant syndrome antidotes

A

dantrolene
bromocriptine

in mild cases - starts with benzos (loraz or diaz)

49
Q

neuroleptic malignant syndrome presentation

A

fever
tachycardia
labile BP
tachypnoea
confusion agitated delirium
dilated pupils
muscle rigidity
rhabdomyolysis
hyperkalaemia
renal and liver failure

Ix: increased WCC, CK, LFTs, hypocalcemia and hypomagnesemia, hyperkalemia, metabolic acidosis

high mortality, 10-20%

caused by antipsychotics and antiemetics (eg domperidone, droperidol, metoclopramide, promethazine)

central dopamine receptor blockade

usually first 2 weeks of antipsychotic therapy
higher risk with rapid dose escalation, switch from one agent to another, IM administration

50
Q

opioid toxicity

A

Constricted pupils
CNS depression
Low temp, HR, BP, RR
Hyporeflexia

Eg heroin, morphine, methadone, oxycodne, codeine

51
Q

oral hypoglycemic antidote

A

octreotide

52
Q

paraphymosis

A

when foreskin is retracted past the coronal sulcus and the prepuce cannot be pulled back over the glans, resulting in venous stasis and severe oedema

53
Q

phimosis

A

inability to retrace prepuce
usally physiological
becomes retractable by age of 3 years in 90%

54
Q

pre pubertal hymen appearance

A

Annular – most common in newborns/infants.

Cresenteric- most commmon early childhod

Fimbriated – i.e. redundant hymen. More common in newborns (or pubertal adolescents) due to effect of oestrogen (maternal oestrogen in the case of newborns).

Septated – normal variant in about 5% of cases only.

55
Q

sedative overdose
eg BZD, barbiturate, alcohol

A

everything goes down

Hypothermia
Bradycardia
Bradypnoea
Hypotension
CNS depression/confusion/coma
Constricted pupils
Hyporeflexia

56
Q

Causes serotoninc syndrome

A

introduction or increase of single seritonergic drug
drug interaction between 2 seritonergic drugs- most common

SSRIs/SNRIs
MAOIs
TCAs
Lithium

Tramadol
Pethidine
Fentanyl

MDMA
LSD
Amphetamines
Cocaine

Ondansatron
Metoclopramide

Sumatriptan

St Johns wart

57
Q

Serotonin syndrome management

A

IV benzodiazepine

Serotonin antagonist if symptoms refractory
Cyproheptadine
Chlorpromazine

58
Q

sulphonylurea antidote

A

octreotide- somatostatin analogue. suppresses insulin release from pancreatic cells

but first give IV glucose bolus –>10% glucose infusion if hypoglycemic

59
Q

Sympathomimetic toxicity
eg cocaine, amphetamine, methamphetamine, ritalin, LSD, MDMA

A

Fever
Tachycardia
Hypertension
Mydriasis - but briskly reactive
Diaphoresis
Psychomotor agitation, paranoia, psychosis
Increased energy
Hyperactive bowel sounds
Reduced pain response

***can only differentiate from sedative/ETOH withdrawal with history

60
Q

Sympathomimetics
Treatment

A

Supportive
IV Benzodiazepines
Cooling for hyperthemia

61
Q

TCA o/d

A

one pill can kill
signs usually within an hour of ingestion
Anticholinergic syndrome
CVS- reduced cardiac contractility and hypotension, widened QRS —> VT/VF, prolonged QT
CNS depression/coma, seizures
tachycardia
vomiting
blurred vision
ataxia
delirium
urinary retention
ileus

Ix: VGG (acidosis), TCA levels, ECG,

Rx: Doses >10-15mg/kg need to be intubated, ventilated and given charcoal
If QRS widened–> sodium bicarbonate bolus

62
Q

warfarin antidote

A

vit k
FFP
prothrombinex

63
Q

ETT tube size equation (uncuffed)

A

(age /4 ) +4

64
Q

Carboxyhaemoglobin

A
  • Product of the reaction between carbon
    Monoxide and haemaglobin
    • Affinity of CO for Hb is 200 x greater than for O2
    • Causes Hb dissociation curve to shift to left
    • –> hypoxia
    • Also binds to intracellular cytochromes, impairing aerobic metabolism

in carbon monoxide poisoning, carboxyhaemoglobin levels provide an approximate guide to status.
Between 10-20%: headache and dyspnoea on exertion;
above 20%: confusion and irritability;
above 50%: unconsciousness, with death likely if exposure is prolonged;
above 70%: death is rapid.

NOT cyanotic

RX: high low O2 via non rebreather, or hyperbaric O2

65
Q

methaemoglobin

A
  • methaemoglobin is an altered state of Hb where ferrous ions (Fe2+) of haem are oxidised to the ferric state (Fe3+) and rendered unable to bind O2
    Main inherited cause: cytochrome B5 reductase deficiency
  • normal level is < 1.5%
  • S/S: cyanosis, chest pain, altered mental state
  • Blood has chocolate brown hue
  • Ix: high metHb
  • Rx: high flow O2 via non rebreather
  • Methylene blue
66
Q

in a child presenting with opiate toxicity, what do you need to do prior to giving naloxone

A

O2 and increase ventilation to normalise CO2 level

67
Q

NSAID overdose

A

risk of mutliorgan dysfunction when >400mg/kg taken (normal dose is 10mg/kg so 40 x normal dose)
Should observe all kids ingesting >200 mg/kg for mild GI and CNS side effects

68
Q

Aspirin overdose

A

Initial hyperventilation with respiratory alkalosis —> metabolic acidosis (High anion gap)
Only symptomatic >150mg/kg (needs monitoring). Severe symptoms >300mg/g

Can use activated charcoal if massive overdose within 1 hour of ingestion

Antidote: IV SODIUM BICARBONATE for urinary alkalisation ; need to correct metabolic acidosis to limit CNS penetration
Apnoea associated with intubation may worsen acidosis and lead to cardiac arrest. Consider pre-loading with sodium bicarbonate

69
Q

Cardiac arrest - shockable rhythm

A

Shock 4J/kg immediately
Recommence CPR 15:2 for 2 minutes
Assess rhythm
Shock if shockable
Adrenaline 10mcg/kg (1:10,000) after 2nd shock, then every 2nd loop (ie after 2nd, 4th, 6th)
Amiodorone 5mg/kg after 3rd shock

Adrenaline 10mcg/kg = 0.01 mg/kg = 0.1ml/kg

70
Q

Cardiac arrest- non shockable

A

Recommence CPR
Adrenaline 10mcg/kg (1:10000) immediately then every 2nd loop (1st, 3rd, 5th cycle)
Recommence CPR 2 minutes
Then assess rhythm

71
Q

Anaphylaxis

A

Cardiac arrest -> cardiac arrest algorithm

No cardiac arrest:

Position flat (or slightly tilted if resp distress worse when lying)

IM adrenaline 10mcg/kg (1:1000) or 0.01ml/kg (max 0.5ml)

72
Q

Bradycardia APLS

A

Adrenaline 10mcg/kg
Atropine if vagal overactivity

73
Q

Status epilepticus

A

Airway
High flow O2
BSL (if <2.6, give glucose 10% 2ml/kg)

At 5 mins:
Midaz 0.15mg/kg IV/IM
OR
Midaz 0.3 mg/kg buccal/intranasal
At 10 mins: 2nd dose as above
At 15 mins: Levetiracetam 40-60mg/kg (over 5 min) or phentoin 20 mg/kg (over 20 min)
5 mins after infusion finished if still fitting: give whatever not given prior
5 mins later: rapid sequence induction and intubation

phenytoin contraindicated in Dravet syndrome (sodium channel blocker)

74
Q

SVT algorithm

A

If shock:
Oxygen via NRB
Vagal manouvre if not delaying other steps
If has vascular access–> IV adenosine 100mcg/kg
If no vascular access –> synchronous DC shock 1J/kg –> 2J/kg
Consider amiodrone
adenosine via rapid push into large vein

If no shock of IV access faster than obtaining defib
Adenosine 100mcg/kg, 200, 300, 400 mcg/kg (max 300mg/kg in neonate)
Consider synchronous DC shock or amiodorone

75
Q

MOA MDMA

A

stimulates release and inhibiting reuptake of serotonin
increases release of nerepinepthine and dopamine and blocks their reuptake to a lesser extent

ie indirect stimulation of serotonin and dopamine receptor

RACP paeds Qld Group (46 decks)

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