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PICU/Tox > PICU/Tox > Flashcards

PICU/Tox Flashcards

1
Q

organophosphate poisoning

A 
opposite of anticholinergic (just remember that everything is wet)
Diarrhea
Urination
Meiosis 
Bradycardia
Bronchospasm
Bronchorrhea
Emesis
Lacrimation
Salivation
Sweaty
inhibits acetylcholinesterase, therefore can't stop acetylcholine from binding at the NMJ
muscle fasciculations
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2
Q

examples of organophosphate

A

nerve gas

insecticides

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3
Q

Treatment

A
  1. atropine - competes with acetylcholine, give in boluses, binds receptors
    acetylcholine can’t bind
    works for both organophosphate and carbamate ingestion, target the improvement of resp symptoms
  2. Pralidoxime - breaks the bond between oganophosphate and acetylcholinesterase (frees the enzyme so it can break it down)
    certain bind permanentantly
    only works if used before the permanent bond forms
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4
Q

Side effects of chloral hydrate

A

respiratory depression
in older kids, unreliable absorption >3 years old
chapter in nelsons

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5
Q

midazolam

A

hypotension
respiratory depression
paradoxical reaction (20% of kids)

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6
Q

Side effects of propofol

A

hypotension
propofol infusion syndrome
- if you use for longer than 12 hours in child
- associated with hemodynamic collapse, cardiac failure, shock and death
hypoventilation
use with caution in hemodynamic unstable and patients
also in kids with egg and soy patient

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7
Q

Reye’s syndrome

A

mitochondrial hepatotopathy
liver failure leads to encephalitis
Aspirin and viral infection (influenza and varicella)

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8
Q

Reye’s syndrome

A 
Increased LFTs and NORMAL bill and NO jaundice 
coagulopathy
high anemia
NO TREATMENT FOR REYE SYNDROME
may need liver
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9
Q

Lightening

A

Systems affected by lightening

  • cardiovascular - most likely
  • respiratory
  • neuro - cerebral edema, seizures
  • kidneys - can get renal failure - can get rhabdo and myoglobinuria
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10
Q

High tension electrical wire burns , climbed a tree then fell on ground

A

ABCDS
entry point and exit point - will have two holes, could have injuries anywhere on the pathway
exit point usually on the legs (first part of the body that touches the ground)
also want to look for compartment syndrome
bowel perforation, liver and spleen hemorrhage
need CT scan
early debridement, tetanus prophylaxis, give aggressive hydration, regardless of how good a patient looks, have to admit them because of possible deep injury takes time to present

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11
Q

Girl who bit electrical cord, mucosal burn on side of mouth

A

don’t have to admit
doesn’t result in conduction of electricity elsewhere
localized burn, don’t extend, since entry/exit are right there
lower voltage

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12
Q

cholinergic toxidrome

A

treat with atropine
(the other option is pralidoxime but more conditions about when it works and only works for organophosphate poisoning (not carbamate)

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13
Q

What is physiostigmine?

A

CHOLINERGIC

used to treat anticholinergic

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14
Q

What is the most important complication of hydrocarbon poisoning

A

lung shit
can’t make surfactant therefore get an ARDS type picture
aspiration

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15
Q

what is sudden sniffing death?

A

heart explodes after sniffing volatile hydrocarbons
myocardium extra sensitive to catecholamines
if they are sniffing and then cause catecholamine release then heart explodes
sudden sniffing death
usually refractory to shocking

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16
Q

if patient with sniffing and cardiac arrest, VF, shocking no help, what to do?

A

beta blocker can try to block B2 receptors

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17
Q

activated charcoal when do you not use

A
  1. hydrocarbons
  2. alcohols
  3. iron
  4. heavy metals
  5. caustic agents - alkali/acids
  6. Lithium

*anything that’s liquid probably aint gonna work
plus heavy things

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18
Q

gastric lavage evidence in ingestions?

A

poor

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19
Q

Classes of hemorrhage?

A 
class i: lost 15% of blood, children can tolerate that, no vital signs changes
class II: lost 15-30% of blood, tachycardia, certain decreased perfusion (slight slow CRT)
class III: 30-40% blood loss, moderate to severe increased HR, BP may start to drop, u/o drops, start to get shock
class IV: >40%, comatose, lose consciousness , essentially dying

used to determine how fast to give blood
I or II: can consider giving 2 boluses first - 1-2 L, if better then rapid responder, don’t need to give them anything else ; if after 15 minutes still having trouble then transient responder, give blood
if III or more: as soon as you have blood, give it (waiting for blood then give something (even if fluids)

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20
Q

most common injury of severe head injury

A

specific learning disability high rates, 2/3 have ADHD

epilepsy 2%

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21
Q

when can you give activated charcoal

A

within 1 hour

if anticholinergic or slow release then might want to give later

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22
Q

when to not reverse diazepam

A

not if seizures or long use

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23
Q

Hemorrhagic shock and encephalitis syndrome (HSES)

A

super high fever
rare
prodrome of fever, URTI sx then hemorrhage etc.

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24
Q

Dog bites infections

A

anaerobes
kingella kingae
capnocytophaga

pasteurella (less likely)
staph and strep
prophylax if on hands (some controversy about when to prophylax)
What big nelson says about dog bites:
types of bites: abrasion, puncture, laceration with or without tissue avulsion
Most common complication: infection ; however infection rate of wounds brought to medical attention 24 hours should not suture them
all hand wounds HIGHLY likely to get infected - so delayed primary closure for all
vs primary closure for facial
very little evidence of anti-microbial agents for prophylaxis of bite injuries - should give Abx to all human bites, and all but most trivial of other bites
also assess tetanus, rabies, hep B/HIV (human)

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25
Q

Cats

A

pasteurella - most likely polymicrobial, but if isolate something pasteurella most likely
staph and strep
cat bites more likely to be infected than dog bites (at least 50%) therefore need to culture these unless very trivial

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26
Q

where do you need operative management?

A
  1. closed fist injury
  2. head injury
  3. extensive wound with lots of dead tissue
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27
Q

which fun drug causes nystagmus

A

PCP

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28
Q

what are 3 non recreational drugs that can cause nystagmus

A
  1. ketamine - eyes go crazy with procedural sedation
  2. barbiturates
  3. phenytoin toxicity

other ones: (baby nelson) ethanol, carbamazepine, dextromethorphan

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29
Q

violent/agitated due on cocaine comes into er

A

physical restraints worsens agitation and hyperthermia
knock them out with benzos
suppotive care and glucose level

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30
Q

swimming and swallowing lots of water

A

get hyponatremia and then can seize

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31
Q

CPS statement

A

no evidence that lessons prevent drowning, just familiarizes them with water

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32
Q

specific fractures for child abuse

A
  1. posterior rib fracture
  2. proximal humeral
  3. femur fracture in non ambulatory
  4. scapula spinal process fracture
  5. metaphyseal distal femoral metaphyseal
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33
Q

Concussion

A

short lived impairment of neuro function which resolves
resolves within 7-10 days usually
4 kinds of categories of features:
- only need one of the features
- history, behaviour, n/v/vomiting, cognitive, sleep disturbances

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34
Q

Jimson Weed

A

atropine and scopolamine, can increase temperature, increases HR, pupil dilatation, photophobia , amnesia

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35
Q

TCA overdose

A

1-2 pills can be enough
anything above 20 mg/kg can have series effect
blocks fast acting sodium channels
impairs cardiac function, get arrythmias
get wide QRS, PVCs, if present with hypotension then poor prognosis, leading cause of death

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36
Q

Treatment of TCA overdose

A

within 1 hour charcoal

urinary alkalization with Na HCO3 if QRS long, hypotension or arrhythmia

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37
Q

Progression of transtentorial herniation

A 
ipsilateral 3rd nerve palsy
contralateral palsy
dilation of the other pupil
then altered rhythm
after breathing get bradycardia 
hypotension is the last step 
decorticate and decerebrate
38
Q

CPS statement if no IV

A

intranasal (0.2 mg/kg), IM (0.2/kg), buccal midaz (0.5mg/kg with max 10)
diazepam - rectal 0.5 mg/kg
ativan - buccal or PR 0.1 mg/kg max 4 mg

39
Q

Traumatic Brain Injury

A 
1st tier:
sedation and analgesia
elevate the head of bed
hyperosmolar agents
2nd tier: 
treat fever - can increase metabolic needs
not too hot and not too cold
also talk about CSF drainage
and hyperventilation
40
Q

Which sedative can help in asthma

A

ketamine, it is also a bronchodilator
dissociates the connection between cortex and limbic system
Hypnotic effect, amnestic effect

41
Q

septo optic dysplasia with hypo pit

A

iv hydrocortisone
don’t need mineral corticoid
ACTH is only the glucocorticoid
renin aldosterone

42
Q

ABCDEs
be safe - admit everyone and do as much as you can for them
think about common and what you can’t miss

A

asdf

43
Q

toxicology

A

often we just watch - do NO harm

44
Q

work up for toxic ingestion

A 
glucose
lytes
renal
LFTs
serum osmoles
blood gas
levels: ethanol, acetamiophen, ASA
Others: toxic alcohols, meds
EKG
urine tox (debatable)
45
Q

Charcoal

A

decreases absorption
usually use within 1 hour
(remember that tylenol works quickly, should be out of stomach after 1 hour) know what you’re trying to get out

46
Q

When to not use charcoal

A

Hydrocarbons
alcohols
iron
electrolytes
mineral acids or bases **basic - neutralized in belly, if drank javex don’t want to vomit
Patient factors:obtunded, loss of airway reflexes, vomiting, non toxic ingestions
never give via NG unless patient is intubated or if it is one of the ingestions that MUST get out - always risk of aspiration

47
Q

When to do whole bowel irrigation and gastric lavage

A

asdf

48
Q

Toxidromes

A
  1. anticholinergic
  2. Cholinergic
  3. opioid
  4. sympathomimetic
  5. sedative hyponotic (same as opioid except not teeny pupil)
49
Q

Jimson weed vs TCA

A

jimson weed makes you hallucinate more

50
Q

Anticholinergic

A 
TCA
antihistamine
antipsychotic
antidepressants
atropine 
(decreased bowels)
51
Q

Treatment of anticholinergic

A

supportive
Sodium bicarb for prolonged QRS, dysrythmias
physostigmine if altered LOC - can make arrhythmia worse (also, relatively contraindicated for TCA according to Nelson)
benzos for seizure

52
Q

Cholinergics

A 
mushrooms
pesticide
nerve gas 
DUMBELLS (aka SLUGDE and the killer Bs)
**everything is wet
53
Q

Treatment of cholinergic

A

decontaminate
supportive
atropine - works for both organophosphate and carbamate
2-PAM (pralidoxime) - only works for organophosphate, and only if perm bond hasn’t formed yet

54
Q

Opiates

A 
morphine, heroine, methadone
sedation, confusion, coma
miosis
hypopnea, bradypnea, resp depression, bradycardia, hypothermia, hypotension
Treatment: suppotive, naloxone if respiratory depression 
fentanyl wears off in an hour
methadone very long
morphine few hours
55
Q

benzos

A

treatment: suppportive
rarely flumazenil - if you gave the benzo and resp depression **causes seizures (can precipitate seizures, don’t give with seizures)

56
Q

Toxic alcohols

A

ethylene glycol and methanol are the scary ones - the metabolites are the worry, stop metabolite formation with fomepizole IV (shuts down the enzyme) (or ethanol) think osmole gaps and anion gaps send specific
ethanol and isopropyl alcohol (makes you drunk but otherwise okay)
since will convert ethanol before ethylene glycol

57
Q

Osmolar gap and anion gap graphed over time of post-toxic alcohol ingestion

A

for alcohols - as alcohol gets metabolized they create other stuff that is counted for in the anion gap
EARLY: osmolar gap increased with nomad anion gap
Late: elevated anion gap with a normal osmolar gap
osmole gap: 2 x [Na mmol/L] + [glucose mmol/L] - 2 salts and a sticky bun
over the course of hours usually
normal Osmolar gap is <10 as per wiki

58
Q

Acetaminophen

A 
do levels 4 hours post, plot on Rumack Matthew
4 stages:
preinjury
liver injury
maximum liver injury
recovery
use antidote within 8 hour no adverse events 
often asymptomatic
59
Q

salicylates

A

tinnitus, hyperventilation, respiratory alkalosis
increased HR, decreased BP, arrhythmia, CNS depression, tremor, seizures
salicylate levels - until they peak and then at least 2 decreasing ones
examples is ASA and wintergreen
only way to get rid of it, dialyse it
can dialyze
can alkalinize the urine (not the best evidence)

60
Q

most unknown things

A

suppotive management, observe 4-6 hours if asymptomatic

benzos for agitation, hallucinations

61
Q

other common ingestions

A

lead ingestion
iron
SSRIS

62
Q

killers in small doses

A

oral hypoglycemics, beta blockers, CCa blockers, TCAs, quinine, opiates, salicylates, loperamide and diphenyoxylate, camphor, podophyllin

63
Q

symptom of ASA overdose

A

either renal failure or potassium

64
Q

TRAUMA

A

think about location
remember the golden hour
basic principles apply - treatment guidelines are very different
100% O2 plus/minus intubation, 2IVs for all trauma patients IO if not, NS fluid, platelets and FFP if more than 1-2 units of blood
D - GCS and pupils
C spine
primary and secondary surveys

65
Q

trauma panel

A

CBC, coags, type and screen, lutes, LFTs, renal function, amylase, lipase
urinalysis for gross hematuria
consider - serum ethanol and other toxins, urine fox screen
imaging CXR ,C spin, consider FAST /CT scan

66
Q

hyperventilate

A

only if in tertiary care centre otherwise you are screwed anyways

67
Q

which pneumos do you need to treat in resus

A

open/tension
hemo- can be massive
cardiac - blunt/tamponade
vessel injury

68
Q

organs for trauma

A
  1. liver
  2. spleen
  3. kidneys
  4. pancreas
    occasionally bowel (seatbelt injuries, handlebars)
69
Q

how to decide what to do for abdo trauma

A

unstable surgery

if stable can do some imaging (i.e. fast)

70
Q

indication for laparotomy

A

HD instability with evidence of abdo injury
penetrating injury to abdo
pneumoperitoneum
multisystem trauma and need other OR procedures if evidence of abdo injury

71
Q

Orthopedic trauma

A

can kill you - neck and back and paralyze you
can bleed - pelvis/femurs - they bleed
the rest are less important
assess neuromuscular status
try to restore anatomic alignment, splint, consult, orthopaedic service

72
Q

gunshot wounds

A

think of trajectory

need a surgeon

73
Q

stab wounds

A

location
depth
need to be explored - bedside or OR

74
Q

burns

A 
100% O2 
early intubation
on exam - Parkland formula
in real life goal directed : urine output, peripheral perfusion 
 D and E
provide analgesia
rule out other trauma
75
Q

Burns

A

calculate BSA 2nd and 3rd

admission: analgesia, BSA >10% location of face, genitals, joints, circumferential, any inhalational burns, child abuse

76
Q

Carbon monoxide poisoning

A

carboxyhemoglobin levels
mild 5-20% - h/a confusion, dyspnea
moderate 20-40 % drowsy, N/V, tachy
severe

77
Q

treatment

A

100% O2 until levels <5%, if anemic transfuse to 100, hyperbaric oxygen, CNS symptoms, CVS symptoms, pregnancy
consult a hyperbaric physician

78
Q

near drowning

A

drown if cold

continue resus and rewarm

79
Q

near drowning

A

not dead till warm and dead
rewarm aggressively until 34 C, warm IV fluids, external warmers, consider lavage (chest, bladder, abdo) CPR continuously, epi, shock if rhythm allows
Don’t forget - C spine injuries, head trauma
**shock and epi not likely to work until 28 C
continue CPR and warm until

80
Q

bad prognosis in drowning

A

> 10 minutes submersion

>25 minutes CPR

81
Q

Foreign body

A

in the airway :
upper -need to get out emergently - stridor, drooling, tripoding, complete obstruction

lower - removal, urgency based on symptoms
suspect if: history suggests if, clinical history suggests it CXR suggests it

82
Q

GI tract

A

only care if in the esophagus - drooling, vomiting, vomiting, dysphagic, FB sensation
most will pass after observation
consult speicalist for removal, if abnormal esophagus consult

83
Q

esophagus button batteries

A

perforation secondary to burn, not if lower down (some controversy)
need a specialist -

84
Q

most things pass

A

sharp, long >5 cm
button batteries can be observed once here
multiple magnets must be removed
follow up XR only if signs of obstruction, abdo pain

85
Q

X-rays for FB

A 
FB 
inspiratory/expirtaory films
fluoroscopy
metal detectors 
lacerations - location, depth, involved structures
close everything with suture
glue if linear, short (<5 cm) not under tension, not for bites, crushes, punctures, mucosal laceration complete
irrigate with water -tap ok
antibiotics if dirty
86
Q

Tetanus

A

are they up to date? how dirty is the wound?

3 doses or more 10 years - give vaccine

87
Q

kid bit by a dog - everyone has vaccine

A 
management
who/where/why
who did the bite - 
why? provoked/unprovoked 
tetanus status
air on the side of treating amox/clav
only close if cleaned very well or on the face
88
Q

Types of wounds to start antimicrobial therapy:

A

(essentailly all but most tribal)

  1. moderate or severe wounds
  2. puncture wounds
  3. facial bites
  4. hand and foot bites
  5. genital bites
  6. wounds in immunocompromised or asplenic people
  7. wounds with signs of infection
89
Q

Sedative agents

A

from our notes:
midazolam - short acting benzo, amnestic effects
ketamine - hypnotic effect, amnestic effect, hallucinogenic effect, can last for weeks, is a bronchodilator

90
Q

Selected drugs used in anaesthesia (table 70-5 e-Nelson)

A

see notes

PICU/Tox (3 decks)

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