Emergency Medicine Flashcards by Kevin G

Organophosphate poisoning

– Presentation?

Salivation, Lacrimation, Polyuria, Diarrhea, Bronchospasm, Bronchorrhea, & respiratory arrest (if severe enough)
– causes massive increase in the level of ACh by inhibiting its metabolism

(Organophosphates = insecticides. Nerve gas has same effects & is more rapid)

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Organophosphate poisoning

– Treatment?

Atropine = 1st step (blocks effects of ACh that’s already increased in the body)

Pralidoxime reactivates acetylcholinesterase, however does not work as instantaneously as Atropine.

Should also remove clothes & wash patient since organophosphates/nerve gas can be absorbed through the skin.

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Gastric Lavage – when is it useful?

Useful w/in 1st hour of ingestion

- removes 50% of pills at 1 hour
- removes 15% of pills at 2 hours

Dangerous to use in AMS (aspiration) or caustic ingestion (burns esophagus & oropharynx)

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Charcoal – when is it useful?

Charcoal is benign & should be given to anyone w/ a pill overdose.
Can remove substances even after being absorbed.
Repeated doses lower blood levels of toxins faster.

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Amount of Acetaminophen for toxicity? Lethality?

Toxicity = 8-10 grams

Fatality > 12-15 grams

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Acetaminophen toxicity – treatment?

N-acetylcysteine (if >8g ingested)

- if overdose was >24 hours ago, NO therapy
- if amount unclear, get a drug level
- Can give charcoal along w/ N-acetylcysteine

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Aspirin overdose – presentation?

- Tinnitus & Hyperventilation
- Respiratory alkalosis progressing to metabolic acidosis (from lactate)
- Renal toxicity & AMS
- Increased anion gap

(causes ARDS & raises PT. Also interferes w/ oxidative phosphorylation & results in anaerobic glucose metabolism, producing lactate)

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Aspirin overdose – treatment?

Alkalinizing the urine, which increases the rate of aspirin excretion.
ex = Bicarbonate

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Aspirin overdose – Blood gas results?

Respiratory alkalosis w/ a low pCO2 & metabolic acidosis w/ decreased Bicarbonate.

pH = alkalotic
pCO2 = low  (normal is ~40)
Bicarb = low  (normal is ~24)

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Anti-depressants that might cause seizures?

Tricyclic antidepressants
(can be prevented by benzodiazepines)

– TCA toxicity is rapidly detected on EKG as widening of QRS complex

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TCA toxicity – EKG changes?

Early changes = widening of QRS complex.

Then, prolongs the QT until Torsade develops.

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TCA toxicity – presentation?

– Anticholinergic effects: Dry mouth, constipation, urinary retention.

– Seizures & Arrythmia (wide QRS, prolonged QT, eventually Torsades)

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TCA toxicity – treatment?

Sodium Bicarbonate. Bicarbonate will protect the heart, it does not increase TCA excretion as it does for Aspirin.

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Caustic ingestion of acids/alkali – treatment?

Flush out the caustics w/ water in high volumes.

Endoscopy is performed to assess degree of damage.

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CO poisoning – blood gas results?

Lactic acidosis

Normal pO2.
Low pH, pCO2, & Bicarbonate.

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CO poisoning – treatment?

100% oxygen

If severe, give Hyperbaric Oxygen.

Severe = CNS symptoms, Cardiac symptoms, or Metabolic acidosis

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Methemoglobinemia – pathophysiology?

Hemoglobin is oxidized & locked in Ferric state, meaning it is brown & does not carry Oxygen.

Occurs as reaction to drugs:

- Benzocaine & other anesthetics
- Nitrites & Nitroglycerin
- Dapsone

Methemoglobinemia – Hg will not pick up O2.
CO poisoning – Hg will not release O2 to tissues.

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Methemoglobinemia – presentation?

- Dyspnea & Cyanosis
- Headache, confusion, seizures
- Metabolic acidosis

(same as CO poisoning)

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Methemoglobinemia – tests?

Best initial = Blood gas

Most accurate = Methemoglobin level

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Methemoglobinemia – treatment?

Best initial = 100% oxygen

Most effective = Methylene Blue
decreases half-life of methemoglobin

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Most likely Dx?

Cyanosis + normal pO2

Methemoglobinemia

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Digoxin toxicity – what electrolyte abnormality predisposes to this?

Hypokalemia, because K+ & Digoxin compete for binding at same site on sodium/potassium-ATPase.
When less K+ is bound, more Digoxin is bound.

Digoxin toxicity – presentation?

Most commonly = GI problems such as nausea, vomiting, & abdominal pain.
Other Sx:
– Hyperkalemia from inhibition of Na/K-ATPase
– Confusion
– Visual disturbance such as yellow halos around objects
– Arrhythmia (can cause any type)

Digoxin toxicity – tests?

Best initial = Potassium level & EKG

Most accurate = Digoxin level

(EKG will show downsloping of ST segment in all leads. Atrial tachycardia w/ variable AV block is the most common digoxin toxic arrhythmia)

Digoxin toxicity -- EKG & cardiac problems?

EKG will show downsloping of ST segment in all leads. Atrial tachycardia w/ variable AV block is the most common digoxin toxicity arrhythmia.

Digoxin toxicity -- treatment?

Digoxin-specific antibodies (Digabind) will remove Digoxin rapidly from circulation. Also control Potassium levels.

Lead poisoning -- presentation?

- - Abdominal pain (lead colic) - - Anemia (sideroblastic) - - Renal tubule toxicity (ATN) - - Peripheral neuropathies (wrist drop) - - CNS abnormalities such as confusion & memory loss

Lead poisoning -- tests?

Best initial = Increased level of Free erythrocyte protoporphyrin Most accurate = lead level

Sideroblastic anemia -- most accurate test?

Prussian Blue stain. | This detects increased iron built up in red cell mitochondria.

Lead poisoning -- treatment?

Chelating agents remove lead from the body. Succimer = oral EDTA & Dimercaprol (BAL) = parenteral agents

Mercury poisoning -- presentation?

Inhaled = interstitial fibrosis (irreversible) Ingested = Neurological problems (nervous, jittery, twitchy, & sometimes hallucinatory)

Mercury poisoning -- treatment?

Chelating agents treat ingested mercury poisoning by removing from the blood. This can also prevent progression of lung fibrosis, but cannot reverse damage.

Methanol (wood alcohol, cleaning solutions, paint thinner) | -- Presentation?

Ocular toxicity -- Retinal inflammation Both methanol & ethylene glycol cause intoxication, metabolic acidosis w/ increased anion gap, & increased osmolar gap.

Methanol (wood alcohol, cleaning solutions, paint thinner) | -- Treatment?

Fomepizole (inhibits alcohol dehydrogenase) & Dialysis (removes toxic metabolite)

Ethylene glycol (antifreeze) -- treatment?

Fomepizole (inhibits alcohol dehydrogenase) & Dialysis (removes toxic metabolite)

Ethylene glycol (antifreeze) -- presentation?

Renal toxicity -- Hypocalcemia, enveloped-shaped oxalate crystals in urine Both methanol & ethylene glycol cause intoxication, metabolic acidosis w/ increased anion gap, & increased osmolar gap.

Snake bites -- beneficial therapy?

- - Pressure - - Immobilization (decreases movement of venom) - - Antivenin (if available)

Black Widow spider bite -- Tx?

Calcium | Antivenin

Brown Recluse spider bite -- Tx?

Debridement, Steroids, Dapsone

Management of Dog, Cat, or Human bites?

- - Amoxicillin/Clavulanate | - - Tetanus vaccination booster if >5 years since last injection

Organism ass'd w/ Dog & Cat bites?

Pasteurella multocida

Organism ass'd w/ Human bites?

Eikenella corrodens

When to give Rabies vaccine in animal bite?

Only if: - - animal has AMS or bizarre behavior - - attack unprovoked, by a stray dog & the animal cannot be observed or diagnosed

What does contrast detect on CT?

Contrast detects mass lesions such as cancer & abscess, NOT blood.

Large Subdural or Epidural hematoma -- management?

1. Intubation & Hyperventilation (decreases pCO2, causing cerebral circulation to constrict & decrease pressure) 2. Mannitol (osmotic diuretic, decreases intravascular volume & ICP) 3. Drainage -- can also give PPI before drainage as proph for stress ulcer.

When to give PPI as prophylaxis for stress ulcer?

- - Head trauma - - Endotracheal Intubation - - Burns - - Coagulopathy (platelets < 50k or INR>1.5) w/ respiratory failure

When are steroids beneficial in CNS disturbances?

They decrease edema around mass lesions & inflammatory conditions like meningitis. They do NOT benefit intracranial bleeding.

Burns -- treatment?

1. 100% oxygen (treats smoke inhalation & CO poisoning) 2. Intubate if there's an airway burn (i.e. if p/w stridor, wheezing, hoarseness, burns inside nasopharynx/mouth) 3. Fluid replacement w/ Ringer Lactate or NS (based on BSA burned)

Most common cause of death several days to weeks after a burn?

Infection | with Staphylococcus

Burns -- fluid replacement amount?

4 mL x (% BSA burned) x weight in kg Head, arms = 9% BSA each Legs, Chest, Back = 18% BSA each Width of hand ~1% BSA

Neuroleptic Malignant Syndrome -- cause, pres, treatment?

Cause = Antipsychotic meds Pres = Elevated body temp, CPK, & K+ Tx = Dantrolene or Dopamine agonists (Bromocriptine, Cabergoline)

Malignant Hyperthermia -- cause, pres, treatment?

Cause = Anesthetics administered systemically Pres = Elevated body temp, CPK, & K+ Tx = Dantrolene

Drowning -- therapy/mgmt?

Airway management & Positive-Pressure Ventilation

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Emergency Medicine Flashcards

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