LAST TEST !! Flashcards
Management of the comatose (poisoned) patient
A - Airway - maintain by positioning, suction, or insertion of artificial nasal or oropharyngeal airway, perform endotracheal intubation B - Breathing - assess quality and depth of respirations, use of supplemental oxygen if needed, BVM/ventilator, monitor arterial or venous blood CO2 and/or arterial blood PO2 C - Circulation - measure pulse and BP, estimate tissue perfusion, continuous ECG monitoring, insert IV, blood draw for glucose/electrolytes/serum creatinine/liver tests, quantitative toxicologic testing D - Drugs
3 Drugs used in management of the comatose (poisoned) patient
■ Dextrose and Thiamine - administer 50% dextrose (50-100ml) by IV bolus in all comatose or convulsing patients unless hypoglycemia is ruled out, administer 100 mg IM thiamine (or in IV fluids) in alcoholic or malnourished patients ■ Opioid Antagonists - Naloxone 0.4-2 mg IV may reverse opioid-induced respiratory depression and coma, may repeat up to 5-10mg, short duration of action (2-3 hours) so repeated doses may be needed and continuous observation for at least 2-4 hours after the last dose is mandatory ■ Flumazenil - Flumazenil 0.2-0.5 mg IV repeated as needed up to maximum of 3mg may reverse benzodiazepine-induced coma, should not be given if patient has coingested a potential convulsant drug, is a user of high dose benzodiazepines, or has a seizure disorder
What is Organophosphate
Insecticide like Malathion and Parathion
Organophosphate poisoning Subjective findings
Nausea, vomiting, cramping, diarrhea, excessive salivation, diaphoresis, headache, blurred vision (miosis), mental confusion, slurred speech, anxiety, drowsiness, urinary incontinence, muscle fasciculations
Organophosphate poisoning physical findings
Miosis, seizures, paralysis, coma, bradycardia, conduction defects, respiratory depression/paralysis
Organophosphate poisoning management (6 things)
■ Maintain airway and assist ventilation ■ Wash skin thoroughly (wear neoprene or nitrile gloves) ■ Activated charcoal if ingested - given 1 gram/kg PO. Insert OG/NG tube to facilitate administration. ■ Atropine is drug of choice for organophosphate toxicity - 2 mg (6 mg if life threatening) in initial dose, then 2 mg IV every 15 min until atropinization occurs - flushing, dry mouth, dilated pupils, tachycardia ■ Administer pralidoxime 1-2 grams IV over 10 min, then constant infusion of 250-500 mg/hr to reverse nicotinic signs (muscle weakness and respiratory depression), not recommended for asymptomatic patients or with known carbamate exposure ■ Place urinary catheter to prevent urinary retention
What are the dangers of tricyclic antidepressants
Tricyclic antidepressants are among the most dangerous drugs involved in suicidal overdose. These drugs have anticholinergic and cardiac depressant properties. Tricyclic antidepressants produce marked membrane depressant cardiotoxic effects. They affect both serotonin and norepinephrine reuptake.
When do TCA symptoms of toxicity occur
Signs of severe intoxication may occur abruptly w/out warning within 30-60 min after acute overdose
TCA toxicity symptoms
-Anticholinergic effects: Dilated pupils, Tachycardia, Dry mouth, flushed skin, Muscle twitching, Decreased peristalsis -Quinidine-like cardiotoxic effects: QRS interval widening, Ventricular arrhythmias, AV block, Hypotension Other symptoms: Hallucination, Confusion, Blurred Vision, AMS, Urinary retention, Seizures, Hypothermia, Hyperthermia
When to admit TCA toxicity to ICU
Evidence of CNS or cardiac toxicity w/in 6 hours of ingestion
Medical management for TCA toxicity (5 meds)
- Activated Charcoal, 1gm/kg: avoid emesis if risk for seizures; INsert large bore OG/NG tube, to facilitate administration of activated charcoal. -Sodium Bicarbonate IV (1-2 mEq/kg); additional boluses every 5 min or 1000 ml D5W with 150 mEq sodium bicarbonate and infuse at 100-150 ml/hr until QRS interval narrows or serum pH exceeds 7.55. (Barkley-Target pH between 7.5-7.55/CMDT pH 7.45-7.5) -Benzodiazepine to control seizure ( e.g. diazepam 5-10mg IV PRN -Cardiotoxicity in patients with overdoses of lipids-soluble drugs have responded to IV lipid emulsion (Intralipid), 1.5 ml/kg repeated one or two times if needed. -If patient still demonstrates signs of delirium, agitation, and enhanced skeletal muscle tone or hyperreflexia, cyproheptadine may be used.Seen in moderate Serotonin syndrome
Supportive measures for TCA toxicity
-Supportive measures such as cooling blankets are used to control temperature -Patient should be monitored for hypotension and should be treated with vasopressors -Prolongation QT interval or Torsades de pointes is usually treated with IV Magnesium or overdrive pacing. -Severe hyperthermia should be treated with neuromuscular paralysis and endotracheal intubation in addition to external cooling measures.
Serotonin syndrome symptoms
Rigidity, hyperthermia, autonomic instability, myoclonus, confusion, delirium, and coma.
What is static pain and what meds should be used?
pain regardless of movement like wound pain, use opioids
What is dynamic pain and what meds should be used?
pain with movement, like joint pain; use NSAIDS
Adjuvants for WHO analgesic ladder (8)
tricyclic antidepressants, SNRIs, anticonvulsants, corticosteroids, muscle relaxers, lidocaine patch, capsaicin, cannabinoids
Step 1 of WHO analgesic ladder
mild pain, nonopioid +/- adjuvant, ASA, NSAID, tylenol
Step 2 of WHO analgesic ladder
+/- adjuvant, codeine, hydrocodone, tramadol, oxycodone
Step 3 of WHO analgesic ladder
+/- adjuvant, morphine, oxycodone, hydromorphone, methadone, fentanyl, toradol
Pain meds for acute pain
COX inhibitors (NSAIDS), tylenol, opioids
Ketorolac
COX 1; analgesic effect equivalent to morphine; can be nephrotoxic
Celecoxib
COX 2
Side effects of COX inhibitors
Side effects gastritis, renal dysfunction, bleeding, HTN, cardiac events: MI, stroke, heart failure. Has ceiling effect
When to use PCA pump
PCA for post op pain keep plasma concentration of opioid within “therapeutic window”
Gender identity definition
a person’s internal sense of gender
Sex definition
assigned sex at birth, based on assessment of external genitalia, chromosomes, and gonads.
Predisposing risk factors to breast cancer for lesbian patients
Lesbians have an increased prevalence of risk factors for breast cancer→ nulliparity, alcohol use, obesity and smoking
HIV testing for gay women patients
Should encourage both partners in a lesbian relationship to have HIV screening prior to sexual contact. Use barrier protection for 6 months until rescreening to determine if they are still negative. If they are monogamous they can then d/c barrier protection
HIV testing for gay men patients
men who have sex with men account for 67% of all new HIV cases in US. all sexuallly active MSM should undergo screening with fourth generation HIV antigen/antibody test at least annually, or more often if high risk. Preexposure prophylaxis is recommended for high risk MSM
