PICU/Tox Flashcards
organophosphate poisoning
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
examples of organophosphate
nerve gas
insecticides
Treatment
- 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 - 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
Side effects of chloral hydrate
respiratory depression
in older kids, unreliable absorption >3 years old
chapter in nelsons
midazolam
hypotension
respiratory depression
paradoxical reaction (20% of kids)
Side effects of propofol
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
Reye’s syndrome
mitochondrial hepatotopathy
liver failure leads to encephalitis
Aspirin and viral infection (influenza and varicella)
Reye’s syndrome
Increased LFTs and NORMAL bill and NO jaundice coagulopathy high anemia NO TREATMENT FOR REYE SYNDROME may need liver
Lightening
Systems affected by lightening
- cardiovascular - most likely
- respiratory
- neuro - cerebral edema, seizures
- kidneys - can get renal failure - can get rhabdo and myoglobinuria
High tension electrical wire burns , climbed a tree then fell on ground
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
Girl who bit electrical cord, mucosal burn on side of mouth
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
cholinergic toxidrome
treat with atropine
(the other option is pralidoxime but more conditions about when it works and only works for organophosphate poisoning (not carbamate)
What is physiostigmine?
CHOLINERGIC
used to treat anticholinergic
What is the most important complication of hydrocarbon poisoning
lung shit
can’t make surfactant therefore get an ARDS type picture
aspiration
what is sudden sniffing death?
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
if patient with sniffing and cardiac arrest, VF, shocking no help, what to do?
beta blocker can try to block B2 receptors
activated charcoal when do you not use
- hydrocarbons
- alcohols
- iron
- heavy metals
- caustic agents - alkali/acids
- Lithium
*anything that’s liquid probably aint gonna work
plus heavy things
gastric lavage evidence in ingestions?
poor
Classes of hemorrhage?
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)
most common injury of severe head injury
specific learning disability high rates, 2/3 have ADHD
epilepsy 2%
when can you give activated charcoal
within 1 hour
if anticholinergic or slow release then might want to give later
when to not reverse diazepam
not if seizures or long use
Hemorrhagic shock and encephalitis syndrome (HSES)
super high fever
rare
prodrome of fever, URTI sx then hemorrhage etc.
Dog bites infections
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)
Cats
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
where do you need operative management?
- closed fist injury
- head injury
- extensive wound with lots of dead tissue
which fun drug causes nystagmus
PCP
what are 3 non recreational drugs that can cause nystagmus
- ketamine - eyes go crazy with procedural sedation
- barbiturates
- phenytoin toxicity
other ones: (baby nelson) ethanol, carbamazepine, dextromethorphan
violent/agitated due on cocaine comes into er
physical restraints worsens agitation and hyperthermia
knock them out with benzos
suppotive care and glucose level
swimming and swallowing lots of water
get hyponatremia and then can seize
CPS statement
no evidence that lessons prevent drowning, just familiarizes them with water
specific fractures for child abuse
- posterior rib fracture
- proximal humeral
- femur fracture in non ambulatory
- scapula spinal process fracture
- metaphyseal distal femoral metaphyseal
Concussion
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
Jimson Weed
atropine and scopolamine, can increase temperature, increases HR, pupil dilatation, photophobia , amnesia
TCA overdose
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
Treatment of TCA overdose
within 1 hour charcoal
urinary alkalization with Na HCO3 if QRS long, hypotension or arrhythmia
Progression of transtentorial herniation
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
CPS statement if no IV
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
Traumatic Brain Injury
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
Which sedative can help in asthma
ketamine, it is also a bronchodilator
dissociates the connection between cortex and limbic system
Hypnotic effect, amnestic effect
septo optic dysplasia with hypo pit
iv hydrocortisone
don’t need mineral corticoid
ACTH is only the glucocorticoid
renin aldosterone
ABCDEs
be safe - admit everyone and do as much as you can for them
think about common and what you can’t miss
asdf
toxicology
often we just watch - do NO harm
work up for toxic ingestion
glucose lytes renal LFTs serum osmoles blood gas levels: ethanol, acetamiophen, ASA Others: toxic alcohols, meds EKG urine tox (debatable)
Charcoal
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
When to not use charcoal
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
When to do whole bowel irrigation and gastric lavage
asdf
Toxidromes
- anticholinergic
- Cholinergic
- opioid
- sympathomimetic
- sedative hyponotic (same as opioid except not teeny pupil)
Jimson weed vs TCA
jimson weed makes you hallucinate more
Anticholinergic
TCA antihistamine antipsychotic antidepressants atropine (decreased bowels)
Treatment of anticholinergic
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
Cholinergics
mushrooms pesticide nerve gas DUMBELLS (aka SLUGDE and the killer Bs) **everything is wet
Treatment of cholinergic
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
Opiates
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
benzos
treatment: suppportive
rarely flumazenil - if you gave the benzo and resp depression **causes seizures (can precipitate seizures, don’t give with seizures)
Toxic alcohols
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
Osmolar gap and anion gap graphed over time of post-toxic alcohol ingestion
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
Acetaminophen
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
salicylates
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)
most unknown things
suppotive management, observe 4-6 hours if asymptomatic
benzos for agitation, hallucinations
other common ingestions
lead ingestion
iron
SSRIS
killers in small doses
oral hypoglycemics, beta blockers, CCa blockers, TCAs, quinine, opiates, salicylates, loperamide and diphenyoxylate, camphor, podophyllin
symptom of ASA overdose
either renal failure or potassium
TRAUMA
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
trauma panel
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
hyperventilate
only if in tertiary care centre otherwise you are screwed anyways
which pneumos do you need to treat in resus
open/tension
hemo- can be massive
cardiac - blunt/tamponade
vessel injury
organs for trauma
- liver
- spleen
- kidneys
- pancreas
occasionally bowel (seatbelt injuries, handlebars)
how to decide what to do for abdo trauma
unstable surgery
if stable can do some imaging (i.e. fast)
indication for laparotomy
HD instability with evidence of abdo injury
penetrating injury to abdo
pneumoperitoneum
multisystem trauma and need other OR procedures if evidence of abdo injury
Orthopedic trauma
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
gunshot wounds
think of trajectory
need a surgeon
stab wounds
location
depth
need to be explored - bedside or OR
burns
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
Burns
calculate BSA 2nd and 3rd
admission: analgesia, BSA >10% location of face, genitals, joints, circumferential, any inhalational burns, child abuse
Carbon monoxide poisoning
carboxyhemoglobin levels
mild 5-20% - h/a confusion, dyspnea
moderate 20-40 % drowsy, N/V, tachy
severe
treatment
100% O2 until levels <5%, if anemic transfuse to 100, hyperbaric oxygen, CNS symptoms, CVS symptoms, pregnancy
consult a hyperbaric physician
near drowning
drown if cold
continue resus and rewarm
near drowning
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
bad prognosis in drowning
> 10 minutes submersion
>25 minutes CPR
Foreign body
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
GI tract
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
esophagus button batteries
perforation secondary to burn, not if lower down (some controversy)
need a specialist -
most things pass
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
X-rays for FB
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
Tetanus
are they up to date? how dirty is the wound?
3 doses or more 10 years - give vaccine
kid bit by a dog - everyone has vaccine
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
Types of wounds to start antimicrobial therapy:
(essentailly all but most tribal)
- moderate or severe wounds
- puncture wounds
- facial bites
- hand and foot bites
- genital bites
- wounds in immunocompromised or asplenic people
- wounds with signs of infection
Sedative agents
from our notes:
midazolam - short acting benzo, amnestic effects
ketamine - hypnotic effect, amnestic effect, hallucinogenic effect, can last for weeks, is a bronchodilator
Selected drugs used in anaesthesia (table 70-5 e-Nelson)
see notes
