Emergency Pediatric Care

Question 1

Vasoactive agents for shock (after failure with fluid resuscitation):

1) Cold shock (poor perfusion)
2) Warm shock (increased HR, bounding pulses)
3) Cardiogenic shock

Answer 1

1) Epi or DA
2) Norepinephrine
3) Milrinone or Dobutamine

Question 2

Causes of miosis

Answer 2

COPS

C holinergics, clonidine

O piates, organophosphates

P hencyclidine, phenothiazine, pilocarpine

S edatives (barbiturates)

Question 3

Causes of myDriasis (Dilated)

Answer 3

AAAS

A nticholinergics (atropine)

A ntihistamines

A ntidepressants (cyclics)

S ympathomimetics (amphetimines, cocaine, LSD)

Question 4

Causes of diaphoretic skin

Answer 4

SOAP

S ympathomimetics (amphetamines, cocaine, LSD)

O rganophosphates

A spirin

P CP (phencyclidine)

Question 5

Causes of red skin

Answer 5

Carbon monoxide (“cherry red” skin)

Boric acid

Question 6

Causes of blue skin

Answer 6

Cyanosis

Methemoglobinemia

Question 7

Conditions with Anion Gap

Answer 7

MUDPILES

M ethanol

U remia

D KA

P henols

I ron, INH

L actate

E thanol, ethylene glycol

S alicylates (ASA, OTC cold meds, herbal preparation, topcial analgesic with oil of wintergreen)

Question 8

Tylenol overdose increases ____ stores, which causes _____ to accumulate.

Answer 8

glutathione

toxic metabolites

Question 9

Symptoms of tylenol overdose:

0-24hrs

24-48hrs

48-96hr

4-14 days

Answer 9

nausea, vomiting, normal LFTs

maybe RUQ pain, slight increase in LFTs

peak of symptoms; AST>20,000, prolonged PT, death from hepatic failure or coagulopathy

recovery or death; symptoms resolve in survivors

Question 10

When is it ok to give activated charcoal?

Answer 10

1. **Tylenol **to prevent further absorption
2. **Anticholinergic agents; **use of physostigmine controversial–SEs include seizures, bronchospasm, hypotension, bradycardia
3. **Carbamazepine; **follow levels (will be delayed peak for 24-72hrs) and renal function
4. Clonidine patch; naloxone has mixed success–if it works gtt is indicated
5. Motrin: >400mg/kg can cause coma and seizures; symptoms occur within 4hrs and resolve in 24hrs (n/v, epigastric gain, drowsniess, lethary, ataxia)
6. Phenothiazine (ex: promethazine, chlorpromazine); treat dystonic rxn with diphendydramine IV or IM
7. TCAs: add sodium bicarb to alkalize serum and prevent dysrhythmias

Question 11

What is Rumack-Matthew Nomogram?

Answer 11

Determines if serum Tylenol concentration will have possible/probable hepatic toxicity

Question 12

If tylenol toxicity is probable or possible using the nomogram, what drug do you start?

Answer 12

N-acetylcysteine IV

or

Acetylcysteine (Mucomyst)

within 8 hrs of ingestion

*Note: no need to follow tylenol levels after toxicity has been determined, just follow LFTs and coags

Question 13

Anticholingeric ingestion symptoms:

(diphenhydramine, amitriptylines, imipramine, atrope, toxic plants)

Answer 13

Dry as a bone: dec sweating and UOP

Red as a beet: flushing

Blind as a bat: myDriasis

Mad as a hatter: agitation, seizures

Hot as a hare: hyperthermia

Question 14

How much iron ingestion classified as mild, moderate, and severe?

Answer 14

Mild: 20mg/kg

Moderate: 40mg/kg

Severe: >60mg/kg

Question 15

What are the 4 overlapping phases of iron toxicity?

Answer 15

1. GI stage (30min to 6hrs): direct damage to mucosa

• n/v, diarrhea, abd pain
• hematemesis, bloody diarrhea (severe)

2. Stability (6-24hrs)
3. Systemic toxicity (12-24hrs)

• hypovolemic shock, cardiovasc collapse
• severe metabolic acidosis (+AG)
• coagnulation disruption, worsens GI bleed
• coma

4. GI/pyloric scarring (2-6wks post ingestion)

Question 16

Toxic ingestion of iron (serum level)?

Answer 16

>500 mcg/dL

*Note: AXR may show pill fragments, but liquid and chewables not generally visable

Question 17

Treatment of iron toxicity?

Answer 17

Chelation with IV deferoxamine if iron >500 mcg/dL or if pt has mod/severe symptoms

DO NOT USE activated charcoal (dose not bind iron) or gastric lavage, or oral deferoxime

Question 18

Most specific salicylate ingestion finding

Answer 18

Tinnitus

Question 19

Which tablet ingestion is known to form a bezoar requiring surgical removal?

Answer 19

Salicylates

***give bicarbonate to alkalinize urine and enhance elimination

Question 20

What are common electrolyte abnormalities in theophylline toxicity?

Answer 20

high glucose and Ca

low K+ and phosphate

**metabolic acidosis **

Question 21

TCA ingestion mnemonic

Answer 21

CCCA

C oma

C onvulsions

C ardiac toxicity = tachycardia, hypo/hyperTN, wide QRS, prolonged QT

A cidosis