Mehl. Intoxication bullet cases + NBME 10 10Q, 86Q. Flashcards
M. 16M + belligerent (karingas) + nystagmus; Tx?
lorazepam (benzo for PCP toxicity).
M. 16M + mutism + constricted pupils; Dx?
PCP intoxication;
student says “Wtf? I thought there was belligerence / bellicosity?” This is one of the presentations on the NBME; if you don’t believe me, Google “Mutism constricted pupils PCP.”
M. 16M + found on floor in school bathroom + sluggish + vitals and pupils normal; Dx?
butane toxicity (inhalant toxicity); student had this on actual USMLE.
M. 14M + ataxia + cognitive decline; Dx?
glue toxicity, not EtOH.
M. 14M + dilated pupils + tachycardia; Dx?
Cocaine
M. 14M + dilated pupils + tachycardia; Tx?
benzo (cocaine).
M. 14M + dilated pupils + visual hallucinations + staying up all night; Dx?
amphetamine
M. 14M + dilated pupils + visual hallucinations + staying up all night; Tx?
benzo
(amphetamine).
M. 3M + microcytic anemia + one-month Hx of poor coordination, anorexia, irritability, and apathy; what
could have prevented this?
“elimination of lead from the child’s home”; Tx = succimer for
kids (if lead levels >44 ug/dL); lead can cause microcytic anemia.
M. 3M + microcytic anemia + one-month Hx of poor coordination, anorexia, irritability, and apathy; Tx?
succimer for
kids (if lead levels >44 ug/dL); lead can cause microcytic anemia.
intoxication of lead
M. 2M + blisters on tongue/mouth + next best step?
fiberoptic endoscopy
M. 2M + blisters on tongue/mouth. Dx?
exposure to drain cleaner.
M. 16F + found by mom 20 minutes ago + consumed bottle of aspirin in suicide attempt + lethargic; what is the acid-base disturbance she has?
mixed metabolic acidosis-respiratory alkalosis
the presumption is we don’t know how long ago she ingested + the lethargy might imply the acidosis has taken effect (acutely, salicylate toxicity causes isolated respiratory alkalosis)
M. acutely aspirin intoxication what acid-base disturbance?
acutely, salicylate toxicity causes isolated respiratory alkalosis
M. aspirin intoxication + lethargy. What acid-base disturbance manifested?
the lethargy might imply the acidosis has taken effect (acutely, salicylate toxicity causes isolated respiratory alkalosis);
M. Aspirin toxicity.
arrows.
Na,
K,
Cl,
bicarb,
CO2,
pH???
another Q wants you to select the literal values for mixed:
normal Na,
Normal K,
normal Cl,
low bicarb,
low CO2,
normal or low pH (the metabolic acidosis will eventually “win” and the patient will become severely acidotic, but rarely a Q might give you a pH in the lower end of normal range if patient is in transition).
M. Tx for aspirin toxicity?
bicarb
It increases excretion via urinary alkalinization -> cannot reabsorb the oxalate (deprotonated, negative charge) form through the tubular walls.
M. 16F + long Hx of depression + taking new medication + large pupils + dry skin + ECG shows QT changes; Dx?
TCA toxicity
M. 16F + long Hx of depression + taking new medication + large pupils + dry skin + ECG shows QT changes; Tx?
sodium bicarb
causes dissociation of TCA from myocardial sodium channels -> TCA is basic, not acidic (in contrast to salicylates), so bicarb actually decreases urinary excretion, but the mechanism as an antidote is different; TCAs cause CCC -> coma, convulsions, cardiotoxicity + triad of anticholinergic, anti-alpha-1-adrenergic, and anti-H1- histaminergic side-effects.
NBME 10. 10Q.
16 y/o boy + is brought to the emergency department by his mother 30 minutes after a 4-minute episode of generalized shaking of his body. One hour ago, the patient’s friend brought him home after a party, at which time, the patient exhibited unusual behavior and said he was a superhero with the ability to fly. The patient subsequently became unresponsive and the episode began. The friend reports that he saw the patient “smoke weed” at the party 2 hours before the episode. On arrival, the patient is diaphoretic and difficult to arouse. Temp. 37.0°C, pulse is 120/min, RR 24/min, BP 135/95 mm Hg. SpO2 99%. The pupils are 6 mm and sluggishly reactive to light. There is horizontal nystagmus. Use of which of the following substances is the most likely cause of this patient’s symptoms?
PCP
NBME 10. 10Q. Phencyclidine (PCP) is an illicit drug that acts on what organ?
central nervous system (CNS) in a variety of ways
NBME 10. 10Q. PCP
It antagonizes N-methyl-D-aspartate receptors leading to excitatory neurotransmitter release, inhibits the reuptake of dopamine, norepinephrine, and serotonin, and stimulates α-adrenergic receptors.
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NBME 10. 10Q. Acute PCP intoxication can lead to what psych/neuro CP?
psychosis, bizarre behavior, agitation, aggression, nystagmus, and ataxia.
NBME 10. 10Q. PCP
Patients may be diaphoretic, tachycardic, and hypertensive as a result of sympathomimetic effects
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NBME 10. 10Q. Chronic PCP abuse can lead to what CP? neural/psych
depression, psychotic symptoms, memory loss, and dysarthria
NBME 10. 10Q. PCP What need to control in the first place in Mx?
Control of psychomotor agitation is the first step in management of patients with PCP intoxication for the safety of the patient and medical staff.
NBME 10. 10Q. PCP MANAGEMENT?
Chemical sedation with benzodiazepines such as intramuscular lorazepam or midazolam can be administered to control symptoms.
NBME 10. 10Q. PCP. once given medications BZD –> what can evaluate next?
Once a patient is adequately sedated, further evaluation can be completed to assess for traumatic injuries or complications of PCP intoxication such as rhabdomyolysis, hyperthermia, and hypertension.
NBME 10. 10Q. In severe cases, PCP intoxication can cause? neuro
seizures, encephalopathy, or a comatose state, which may necessitate emergent management, intubation, and supportive care.
NBME 10. 10Q. kitas ats. Diazepam (Choice A), a benzodiazepine, and ethanol (Choice B) are CNS depressants that, in toxic doses, can cause …..CP?
slurred speech, ataxia, emotional lability, and memory lapses.
NBME 10. 10Q. kitas ats. marijuana. CP?
is a hallucinogen that causes euphoria, paranoia, hallucinations, cognitive slowing, conjunctival injection, and dilated pupils.
NBME 10. 10Q. kitas ats. Methamphetamine. CP?
is a CNS stimulant that causes euphoria and increases sympathetic tone, leading to tachycardia, hypertension, pupillary dilation, and restlessness.
Because of increased synaptic dopamine, hallucinations and paranoia can occur.
NBME 10. 86Q. A 3-year-old girl is brought to the emergency department after her mother found her in the kitchen next to an open bottle of drain cleaner that had been stored under the sink. The bottle was still almost full, but some of its contents were spilled on the patient’s clothes and on the floor. On arrival, she is alert, crying, and drooling but in no respiratory distress. Her pulse is 120/min, respirations are 30/min, and blood pressure is 95/70 mm Hg. The mouth and oral mucosa is bright red, but there are no ulcers in the oropharynx. The lungs are clear to auscultation. Abdominal examination shows no abnormalities. The extremities are well perfused. An x-ray of the chest shows clear lung fields and normal cardiac silhouette and mediastinum. Which of the following is the most appropriate next step in management?
Esophagoscopy
NBME 10. 10Q. drain cleaners.
Drain cleaners are a common cause of caustic ingestions in children. They contain sodium and potassium hydroxides, alkali that are proton acceptors and strong nucleophiles.
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NBME 10. 10Q. drain cleaners. CP?
Alkali ingestion leads to liquefactive necrosis, lactic acidosis, and tissue penetration and ulceration.
It can cause chemical burns and ulcerations of the tongue, airway, and esophagus, resulting in stridor, hoarseness, vomiting, and drooling.
If severe, esophageal perforation can ensue, leading to free air in the mediastinum, known as Boerhaave syndrome, a surgical emergency.
NBME 10. 10Q. drain cleaners. Tx
Treatment is initially focused on supportive measures including airway management and fluid resuscitation.
NBME 10. 10Q. drain cleaners.
Visible lesions in the oropharynx increase the likelihood of distal gastrointestinal lesions. Patients should be emergently evaluated with esophagoscopy (endoscopy) to assess for visceral injury and guide management.
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NBME 10. 10Q. drain cleaners. for severe cases what need to administrate?
For severe injuries, treatment involves steroid administration.
NBME 10. 10Q. drain cleaners. Should we give activated charcoal?
Activated charcoal is contraindicated because of the coating of ulcerated mucosa, potential for extraluminal spread into the mediastinum, and impairment of visualization on endoscopy.
Administration of activated charcoal (Choice B) would be unlikely to be beneficial and would not be safe in a patient who is drooling and has likely tissue injury secondary to alkali ingestion. Charcoal, if aspirated, can be harmful to the pulmonary parenchyma and cause aspiration pneumonitis.
In contrast, other toxic ingestions may required charcoal.
NBME 10. 10Q. drain cleaners. gastric lavage (Choice E) was a common gastric decontamination procedure for oral toxic ingestions that is no longer widely recommended.
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NBME 10. 10Q. drain cleaners. barium swallow - in dysphagia
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