Emergency Medicine/ Toxicology Flashcards
What should be done initially on CCS if a pt presents to the ER with acute change in mental status of unclear etiology?
Give naloxone, thiamine, dextrose and oxygen and saline while checking toxicology screen
When is gastric emptying useful?
First hour of overdose
What is the best initial step in management of a pt presenting to the ER with acute change in mental status of unclear etiology?
Administer nalxone, dextrose, and thiamine
Correct for opioid overdose, hypoglycemia, and alcoholic issue
What six things should be done simultaneously for an overdose case on the CCS?
- specific antidote (or dextrose, thiamine and naloxone)
- toxicology screen
- charcoal
- CBC, chemistry, urinalysis
- psychiatric consult (if suicide attempt)
- oxygen (for possible carbon monoxide)
What is the specific antidote for acetaminophen overdose?
N-acetyl cysteine (prevents liver toxicity in first 24 hours)
What is the specific antidote for aspirin overdose?
bicarbonate (to alkalinize urine)
What should be avoided in benzodiazepines overdose?
flumazenil (will precipitate benzo withdrawal and seizures)
What is the specific antidote for carbon monoxide poisoning?
100% oxygen (hyperbaric in some cases)
What is the specific antidote for digoxin overdose/ poisoning?
digoxin-binding antibodies (digiband)
What is the specific antidote for ethylene glycol overdose?
fomepizole or ethanol (along with dialysis)
What is the specific antidote for methanol overdose?
fomepizole or ethanol (along with dialysis)
What is the specific antidote for methemoglobinemia?
methylene blue (with 100% oxygen)
What is the specific antidote for neuroleptic malignant syndrome?
bromocriptine or dantrolene
What is the specific antidote for opiates overdose?
naloxone
What is the specific antidote for organophosphate overdose?
atropine and/or pralidoxime
What is the specific antidote for tricyclic antidepressants overdose?
bicarbonate (protects the heart)
What two diseases/ disorders lowers the amount of acetaminophen needed for toxicity and fatality in overdose?
- liver disease
2. alcohol abuse
What are the symptoms of acetaminophen overdose in the first 24 hours and between 48-72 hours after ingestion?
24 hours: nausea and vomiting
48-72 hours: hepatic failure
What is the lowest acetaminophen level in a normal pt in which it is toxic to the patient?
10 grams
What is the lowest acetaminophen level in a normal pt in which it is a fatal to the patient?
15 grams
What is the next best step in management of a pt presenting with acetaminophen ingestion however the amount of ingestion is equivocal?
obtain acetaminophen level
An overdose pt presenting with hyperventilation, respiratory alkalosis followed by metabolic acidosis with elevated anion gap, renal insufficiency, elevated prothrombin time (PT), confusion, fever and tinnitus most likely overdosed on ….
aspirin (salicylate)
What five things should be done on CCS in a case of aspirin overdose?
- CBC
- chemistry panel
- arterial blood gas (ABG)
- coagulation study (PT, PTT, INR)
- salicylate (ASA) level
What is the treatment for aspirin overdose?
- alkalinize urine (increase excretion)
- charcoal (block absorption)
- dialysis (if severe)
What is used to to alkalinize the urine in overdose cases (salicylates, TCAs, phenobarbital, chlorpropamide)?
D5W with 3 amps of bicarbonate
On CCS, what three levels should always be checked in an overdose patient?
- aspirin (salicylate)
- acetominophen
- alcohol
(high frequency of co-ingestion)
A pt presents to the ER with fatigue, headache, shortness of breath, lightheadedness, and disorientation after a fire or being snowed in and using a wood-burning stove, and feels better when shoveling snow outside most likely suffers from…
Carbon Monoxide Poisoning
cant release oxygen to tissue
What is the best initial step in management for a patient being rescued from a fire?
call ambulance and give 100% oxygen (until obtain carbon monoxide level)
A pt presents with nausea, vomiting, diarrhea, seeing yellow halos around objects, blurred vision, arrhythmia, hyperkalemia and encephalopathy most likely suffers from…
Digoxin Toxicity
tx: digoxin binding antibodies if severe –> CNS and cardiac abnormalities
A pt presents with intoxication, metabolic acidosis with increased anion gap, renal insufficiency, hypocalcemia, and kidney stones most likely suffers from…
Ethylene Glycol intoxication
tx: ethanol/ fomepizole and dialysis
A pt presents with intoxication, metabolic acidosis with increased anion gap, visual disturbances and retinal hyperemia most likely suffers from …
Methanol intoxication
tx: ethanol/ fomepizole and dialysis
A pt presents cyanotic with shortness of breath, dizziness, headache, confusion, seizures, normal pO2, chocolate brown colored blood, and a history of nitrate/ anesthetic/ dapsone/ med ending in “caine”/ nitroglycerin use most likely suffers from ..
Methemoglobinemia
hemoglobin locked in oxidized state so cant pick up oxygen
What are the two diagnostic tests for methemoglobinemia?
- normal pO2 on arterial blood gas with chocolate brownish blood
- methemoglobin level
A pt presenting with elevated CPK levels, hyperkalemia, muscle rigidity, hyperthermia, CNS dysfunction (confusions, seizures), arrhythmia, a history of anti-psychotic medication use and possibly rhabdomyolysis most likely suffers from…
Neuroleptic Malignant Syndrome
tx: dopamine agonists –> cabergoline/ bromocriptine/ dantrolene
A pt presenting with elevated CPK levels, hyperkalemia, muscle rigidity, hyperthermia, CNS dysfunction (seizures, confusion), a history of anesthetic use, and possibly rhabdomyolysis most likely suffers from…
Malignant Hyperthermia
tx: dantrolene
A pt presents with hyperthermia, excessive sweating, nausea, vomiting, and possibly hyperkalemia and rhabdomyolysis after physically exerting themselves in the summer time most likely suffers from …
Heat Exhaustion
What is the treatment for heat exhaustion?
- normal saline IV (at room temp)
2. removal of pt from hot environment
A pt presents with hyperthermia, dry skin, confusion, seizures, hyperkalemia, arrhythmia, and possibly rhabdomyolysis after physically exerting themselves in the summer time most likely suffers from …
Heat Stroke
What is the treatment for heat stroke?
- removal from heat
2. spraying pt with water/ fanning pt in air conditioned room/ applying ice baths/packs
What causes death in opiate toxicity?
respiratory depression
A crop duster/ pt involved in nerve gas attack presents with salivation, lacrimation, urination, diarrhea and wheezing from bronchospasm most likely suffers from …
Organophosphate poisoning
inhibits Acetylcholinesterase so increases ACh activity
What is the best initial treatment for organophosphate poisoning?
- Atropine
2. and remove clothes and was the rest of pt off
What is the most effective treatment for organophosphate poisoning?
pralidoxime
A pt with a history of depression presents after overdose resulting from a suicide attempt with dilated pupils, dry mouth, constipation, urinary retention, and possibly CNS or cardiac abnormalities most likely suffers from …
tricyclic antidepressant poisoning
What is the most urgent step in management of a pt with suspected tricyclic antidepressant poisoning?
obtain EKG (assess for widening of QRS that can lead to ventricular tachycardia or torsade de pointes)
What is the next best step in management of a pt with suspected tricyclic antidepressant poisoning who also has widening of the QRS on EKG?
give bicarbonate and transfer to ICU
A pt presenting with abdominal pain without tenderness, rigidity, and hypocalcemia with a possible visible bump on the skin most likely suffers from …
black widow spider bite
tx: antivenin
A pt presenting with local necrosis, bullae formation and dark lesions after an insect bite most likely suffers from …
Brown recluse spider bite
tx: debriding wound and possible steroids and dapsone
What are the four indications for intubating a pt who was involved in a fire (after giving 100% oxygen for possible carbon monoxide poisoning)?
- hoarsenss
- wheezing
- stridor
- burns inside nose or mouth
(signs of respiratory injury)
What is the next best step in management of a pt involved in a fire after giving 100% oxygen and assessing for need for intubation (and performing intubation if needed)?
give 4 ml of lactated ringers/ normal saline for each percentage of body with 2nd or 3rd degree burn per kilogram
(give fluids to rehydrate)
What is the most urgent step in management of an alcoholic that is found sleeping outside in the winter time?
EKG (assess for J-waves of Osborn –> similar to ST segment elevations signifying hypothermia)
A pt presenting with a rock hard, painful red eye, corneal haziness and a fixed midpoint pupil most likely suffers from …
Acute angle closure glaucoma
ophthalmologic emergency
What is the best initial therapy for acute angle closure glaucoma?
pilocarpine drops (constrict pupil) with or without mannitol (osmotic diuretic to open angle)
Other than pilocarpine and mannitol, what other medical interventions are used to treat acute angle closure glaucoma? (4)
- acetazolamide (decrease aqueous humor production)
- prostaglandin analogs (latanoprost, travoprost)
- beta blockers topically (timolol)
- alpha agonists (apraclonidine)
A pt presents with sudden loss of vision like a curtain is coming down most likely suffers from …
retinal detachment
What is the best initial steps in management of a pt with suspected retinal detachment? (2)
- consult ophthalmology
2. dilated retinal exam
What is the treatment for retinal detachment? (3)
- tilt head back
- reattach retina (surgery, cryotherapy or injecting expansile gas into eye)
- if 1 and 2 fail, then place band around eye to get retina close to sclera
What is the diagnostic test for suspected glaucoma?
tonometry
A pt presents with bilateral watery discharge from eyes and the eyes are itchy and red most likely suffers from …
viral conjunctivitis
A pt presents with unilateral purulent discharge from eye, red eye and eyelids stuck together most likely suffers from …
Bacterial conjunctivitis
tx: topical antibiotics
A pt presenting with a red eye and associated photophobia most likely suffers from …
uveitis
What is the diagnostic test for suspected uveitis?
slit lamp exam
What is the treatment for uveitis?
steroids
A pt presents with a red eye and history of trauma/ contact lens use most likely suffers from …
Corneal abrasion
What is the diagnostic test for suspected corneal abrasion?
fluorescein stain (detects abrasion)
