Physical Med 2

Question 1

Radiation

Acute Effects

Answer 1

Localized damage – to an exposed body part

Acute Radiation Syndrome – large dose to body
Bone marrow syndrome– infection, hemorrhage.
Gastrointestinal (GI) syndrome – GI tract & bone marrow damage  infection, dehydration, & electrolyte imbalance – death w/in 2 weeks.
Cardiovascular (CV)/ Central Nervous System (CNS) syndrome – collapse of the circulatory system, intracranial edema / hemorrhage / infection – death w/in 3 days

Question 2

Radiation – Acute Effects

Tx

Answer 2

WHO & CDC websites on treatment of acute illness
National Nuclear Security Administration – 24h expert consult line
Decontamination if needed
Monitoring & supportive care

Question 3

Radiation – Delayed Effects

general

Answer 3

Occupational exposure
Radiation therapy
Medical imaging

Carcinogenesis – worse for prenatal & pediatric exposure; type / dose / duration of radiation also play a factor

Question 4

Poisoning and overdose

Answer 4

Poisoning – exposure to a chemical that causes a negative effect

Overdose – a subcategory of poisoning – the chemical in this case is a medication or drug

Usually from ingestion – also from inhalation, skin / mucous membrane exposure, injection

Question 5

Non-toxic ingestion

Answer 5

– exposure to
a known chemical
with no known exposure hazards
that happened accidentally
that resulted in no symptoms

Question 6

Question 7

OSMOLAR GAP

“MAD GAS”

Answer 7

M-Mannitol- diluent for drugs, kid laxative
A-Alcohols
D-DMSO degreaser, paint thinner, anifreeze
G-Glycerol sweetener
A-Acetone
S-Sorbitol sweetener for DM, cosmetics, pharma

Nl osmolar gap < 10 mOsm/L

Osm gap = Osm measured – Osm calculated
Measured = Lab determination
Calculated = 2(Na) + BUN/2.8 + Glucose/18

Question 8

Resuscitation Concepts

Answer 8

Antidotes are rarely needed in the early management

Evaluation and stabilization of the ABCs should always come first
The prime exception would be cyanide poisoning where 100% O2, amyl nitrite inhaler, IV sodium nitrite and sodium thiosulfate are administered immediately

Question 9

Decontamination
Charcoal

Answer 9

Activated charcoal
- owing to its large surface area, AC can absorb many drugs
- does not bind with lead, lithium, iron, or potassium but may be indicated for coingestions
- poorly binds with alcohols and cyanide
Multi-dose AC may enhance systemic elimination of some drugs
- Carbamazepine, dapsone, theophylline

Question 10

Activated charcoal contraindications

Answer 10

Do not give in suspected esophageal or peptic ulcer perforation
Multi dose activated charcoal
One dose is usually effective
Some circumstances require multiple doses

Question 11

Charcoal indications

Answer 11

Multi dose activated charcoal
Indications:
Ingestion of very large doses
Substances that form bezoars
Substances that slow gut function
After initial dose of 1gm/kg:
0.25-0.5 gm/kg q 1-4 hours

Question 12

Cathartics and contraindications

Answer 12

Shown to decrease the transit time for the passage of the charcoal and subsequent adsorbed toxin
Should not be used for:
- children under 5
- substances known to cause diarrhea
- intestinal obstruction
- ingestion of a caustic material

Question 13

“Coma cocktail”

Answer 13

D-dextrose
O-oxygen
N-narcan
T-thiamine (or: “thioglucan”)

“Don’t forget don’t”
- Abnormalities in breathing are not usually the direct effect of a toxin, but rather a result of the patient’s altered level of consciousness

Question 14

Resuscitation Concepts

Answer 14

Glucose
50ml of D50 IV in adults
1gm/kg in children

Narcan
0.1-2.0mg IV
Competitive opioid antagonist
Consider restraints prior to admin
(may precipitate an acute withdrawal syndrome)

Thiamine
100mg IV
Indicated if you think there is a history of EtOH/malnutrition

Question 15

Toxidrome

general

Answer 15

A toxic “fingerprint”

Physiologically based abnormalities that are known for many substances and typically helpful in establishing a diagnosis when the exposure is not well defined

ToxidromesThe term toxidrome refers to the collection of signs andsymptoms that are observed after an exposure to a substance(a toxic “fingerprint”). Toxidromes include grouped,physiologically based abnormalities of vital signs, generalappearance, skin, eyes, mucous membranes, lungs, heart,abdomen, and neurologic examination that are known for manysubstances and typically helpful in establishing a diagnosis whenthe exposure is not well defined (Table 151-2). Similarly, certainclinical findings may narrow the etiologic possibilities (Table 151-3).

Question 16

Question 17

Anticholinergic toxicity

general

Answer 17

Results from medications or plant metabolites that block the binding of acetylcholine to muscarinic receptors

TCAs, phenothiazines, antihistamines, antiparkinsonian, scopolamine, atropine, Jimsonweed, etc

Question 18

Anticholinergics“Alice in Wonderland” (5)

Answer 18

“Mad as a hatter”
- auditory/verbal hallucinations
- confusion, severe agitation
“Blind as a bat”
- mydriasis (dilation of eye)
“Red as a beet”
- flushed skin from vasodilatation
“Dry as a bone”
- dry skin and mucous membranes
“Hot as a hare”
- hyperthermia

Question 19

TOXIDROMES suspicions for anticholinergic

Answer 19

Always suspect anticholinergic toxicity in patients who present with unexplainable mental status changes

Antihistamine overdose (particularly diphenhydramine) is the most common presentation

In young children, “just a few pills” with anticholinergic properties, such as orphenadrine (Norflex), can cause significant toxicity

Question 20

toxidromes

concerns in elderly

Answer 20

• Use of multiple medications with anticholinergic properties
  - Toxicity may manifest itself as new-onset delirium

Question 21

TOXIDROMES

Tx for severe anticholinergic syndrome

Answer 21

Supportive care for anticholinergic syndrome – may include cooling & sedation

Physostigmine for severe anticholinergic syndrome (agitated delirium) – avoid if long QT on EKG d/t risk of bradyarrhythmias

Question 22

Question 23

Sympathomimetics

examples

Answer 23

amphetamine(Evekeo)
cathinone(found inCatha edulis, khat)
cocaine(found inErythroxylum coca, coca)
ephedrine(found inEphedra)
lisdexamfetamine(Vyvanse)
MDMA(Ecstasy, Molly)
methamphetamine(Meth, Crank, Desoxyn)
methylphenidate(Ritalin)
oxymetazoline(Afrin,Vicks Sinex)
pseudoephedrine (Sudafed)

Question 24

Answer 24

hot and wet

Question 25

Question 26

Cholinergic agents

general

Answer 26

organophosphate insecticides, herbicides, rodenticides
- nerve agents (VX, sarin)

Inhibit the enzyme cholinesterase in the nervous system leading to an accumulation of the neurotransmitter acetylcholine in the CNS, autonomic nervous system, and neuromuscular junction

Question 27

CHOLINERGIC “SLUDGE”

Answer 27

S-Salivation
L-Lacrimation
U-Urination
D-Defecation
G-Gastrointestinal (cramping)
E-Emesis
plus “KILLER BEES” (bronchospasm, bronchorrhea, bradycardia)

Question 28

cholinergic syndrome

Tx

Answer 28

First give atropine to reverse excess acetylcholine; may require repeat doses

Then give pralidoxime (2-PAM-Cl) to reactivate cholinesterase

Question 29

agitation

Question 30

eye decontamination

Answer 30

Eyes
IMMEDIATE COPIOUS irrigation with NS
Very uncomfortable-2 man procedure
May require topical anesthetic in order to tolerate irrigation
End point is a tear pH of about 7.5-8.0
pH of NS is 5.6-so, allow several minutes for the pH to level out after irrigation

Question 31

Hemoperfusion
Most commonly used for

Answer 31

Dialysis + a charcoal filter
Helpful for the toxin with a large molecular weight or if protein bound
Most commonly used in theophylline overdose

Question 32

Answer 32