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Pediatric Emergencies Exam 2 > Toxidromes 3 > Flashcards

Toxidromes 3 Flashcards

1
Q

Sympathomimetics Toxidrome: Signs and Symptoms (4)

A
  1. Cardiovascular
    a. Hypertension
    b. Tachycardia
    c. Hyperthermia
    d. Tachypnea
  2. GI - Bowel sounds present
  3. CNS
    a. Dilated pupils
    b. Psychomotor agitation
    c. Mydriasis (large pupils)
  4. Skin- Diaphoresis
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2
Q

Sympathomimetic Responses (2)

A
  1. Increased catecholamine surge will typically produce Hypokalemia, Hyperglycemia, Metabolic acidosis, low bicarbonate
  2. Potential rhabdomyolysis due to extreme agitation
    i. CK LEVELS – to test for rhabdomyolysis
    ii. Do CK levels with a sympathomimetic ingestion
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3
Q

Cocaine Abuse (3)

A
  1. Insufflation
    a. (snorting)
    b. Reasonable high
    c. Drug has short life and user seeks more
    d. Safer but less efficient
  2. Smoking (free basing)
    a. Stronger and faster
    b. Pulmonary complications
  3. Injecting (speed balling)
    a. User cut cocaine with heroin
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4
Q

How can children get cocaine? (5)

A
  1. Mother in child abuse
  2. Breast milk
  3. Accidentally: leaving around
  4. Intentional exposure from parents blowing it into child face
  5. Unintentional exposure from passive smoke
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5
Q

Cocaine Effects (7)

A
  1. Interacts with alcohol creating new compound in liver causes euphoria 45-60 minutes later
  2. Increased risk for seizure if using nifedipine (Calcium channel blocker)

Central venous effects:

  1. Vasoconstriction
  2. Tachycardia (200 range)
  3. BP increase (systolic in 200)
  4. Cocaine can lead to Coronary syndrome and Pulmonary hemorrhage
  5. TEMPERATURE IS HIDDEN VITAL SIGN
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6
Q

Adolescence and Cocaine Use (3)

A
  1. Pneumomediastinum from inhaling smoke and performing valsalva maneuver
  2. Screening: look form metabolites of cocaine
  3. In OD: pale, clammy and cool, cardiac rhythm abnormalities
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7
Q

Summary of sympathomimetic effects (4)

A

Ex: cocaine

  1. Large pupils
  2. Elevated HR
  3. Wet skin
  4. Decreased GI motility
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8
Q

Summary of cholinergic effects (4)

A

Ex: organophosphate

  1. Small pupils
  2. Decreased HR
  3. Wet skin
  4. Elevated GI motility
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9
Q

Summary of anticholinergic effects (4)

A

Ex: diphenhydramine

  1. Large pupils
  2. Increased HR
  3. Dry skin
  4. Decreased GI motility
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10
Q

Summary of opioid effects (4)

A

Ex: heroin

  1. Decreased HR
  2. Normal HR
  3. Normal skin
  4. Decreased GI motility
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11
Q

New toxidromes (4)

A
  1. Case of l7 year old woman who had a witnessed seizure at home
  2. Woke up complaining of bi-temporal headache
  3. Patients have bizarre interest in light
  4. Serum Na: ll4
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12
Q

MDA (6)

A
  1. Similar effects to MDMA
  2. MDA is a metabolite of
  3. MDMA
  4. Acts on the CNS by releasing norepinephrine and blocking its reuptake
  5. Oral or IV
  6. Frequently adulterated with other drugs
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13
Q

MDA Signs and Management (2)

A
  1. Hypertension –> IV nitro, nitroprusside or alpha blocker such as phenotolamine
  2. Rhabdomyolysis –> Strict attention for fluids and electrolyte balance with alkalization of urine
    * Need to fluid restrict
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14
Q

Amphetamine Analogue (MDA, MDMA, MDEA) Effects (18)

A
  1. Increased CNS and hallucinogenic effects

Cardiovascular:

  1. Tachycardia
  2. Hypertension
  3. Dysrhythmia
  4. Flushing
  5. Angina

Neurologically:

  1. Diaphoresis
  2. headache
  3. altered mental status
  4. seizures
  5. Intracranial hemorrhage
  6. mydriasis
  7. BRUXISM: pacifier around neck: ectasy
  8. Severe fatigue following use
  9. Hyperthermia – Fluid and electrolyte imbalance due to water intake
  10. Marathon dancing is associated with its use
  11. Death associated with amphetamine use
  12. Subarachnoid hemorrhage and ruptured aneurysm
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15
Q

Acute overdose of amphetamine analogues (5)

A
  1. Airway, breathing
  2. Control of agitation and sedation is needed
  3. Control hyperthermia
  4. Rhabdomyolysis can be a control.
  5. Benzodiazepines such as Ativan for seizure
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16
Q

Gamma Hydroxybutyrate (GHB) (date rape drug) (10)

A
  1. Rapid progression to flaccid areflexic coma
  2. Preserved pulse and BP
  3. CNS depression and respiratory depression
  4. ‘DATE RAPE’ drug (liquid ecstasy, liquid X, Grievous bodily harm)
  5. GHB used until l990 as an OTC sedative
  6. Severe reactions including seizures and coma
  7. Produces dopamine release in substantia nigra producing euphoria
  8. GHB may be protective against hypoxic tissue injury
  9. Can have mild hypothermia and asymptomatic bradycardia
  10. Hypotension can occur if alcohol is used with this
17
Q

Treatment of GHB (5)

A
  1. Watch and stimulate patient
  2. Must really determine that respirations can’t be stimulated
  3. May respond to naloxone
  4. Produces pattern of normal rapid eye movement
  5. Best sleep the patient has had
18
Q

Salicylates (ASA) (7)

A
  1. Weak acid, rapidly absorbed
  2. Enteric coated has delayed absorption
  3. Toxic dose: 160 mg/kg
  4. Lethal dose 480 mg/kg
  5. Mixed respiratory alkalosis-metabolic acidosis
  6. Stimulates respiratory drive causing hyperventilation, but limits ATP production → metabolic acidosis
  7. Oil of wintergreen, 1ml = 1400mg of aspirin
19
Q

Salicylates overdose etiology (6)

A
  1. Stimulate the respiratory center of medulla
  2. Hyperventilation and respiratory alkalosis (compensatory for metabolic acidosis)
    a. Blowing off the ingested acid
  3. Compensatory bicarbonates excretion
  4. Increased pyruvate and lactate cause metabolic acidosis
  5. Toxic if >/=150 mg/kg
  6. Found in antihistamine/decongestant combos, anti-diarrheal, herbal meds, oil of wintergreen, sunscreens
20
Q

Salicylates signs and symptoms (10)

A
  1. Nausea and vomiting
  2. Tinnitus
  3. Tachypnea and hyperpnea
  4. Hypotension
  5. Oliguria
  6. Pulmonary edema
  7. Minor rise in temperature
  8. Respiratory alkalosis and metabolic acidosis
  9. Ketones in urine
  10. 1-2 drops of ferric chloride solution turns pink is positive for ASA
21
Q

Salicylates Dif Dx (7)

A
  1. Other causes of anion gap metabolic acidosis
  2. MUDPILES
  3. Reye syndrome
  4. Sepsis
  5. Encephalopathy
  6. Diabetic ketoacidosis
  7. Renal failure
22
Q

Salicylates Clinical Presentation (9)

A
  1. Tachypnea, tachycardia, hyperthermia
  2. Respiratory alkalosismetabolic acidosis
  3. Altered serum glucose
  4. AG metabolic acidosis (MUDPILES)
  5. Dehydration (vomiting, tachypnea, sweating)
  6. Abd. pain/n/v
  7. Tinnitus, hearing loss
  8. Lethargy, seizures, altered mental status
  9. Noncardiogenic pulmonary edema
23
Q

Metabolic Acidosis with High Anion Gap: Causes (MUDPILES)

A 
METHANOL
UREMIA
DIABETIC KETOACIDOSIS
PARALDEHYDE AND PHENORMIN
ISONIAZID AND IRON
LACTIC ACIDOSIS
ETHANOL AND ETHYLENE GLYCOL
SALICYLATES
24
Q

Evaluation of ASA Overdose (6)

A
  1. Lytes, ABG, LFTs, CBC, pregnancy test, urine PH
  2. Serum salicylate levels (toxicity at 25mg/dl)
  3. Toxicity correlates POORLY with levels
  4. Evaluation with DONE normogram based on single ingestion of regular
  5. ASA at levels drawn 6 hrs. after ingestion
  6. Underestimates toxicity in cases of severe academia or chronic ingestion
25
Q

Therapy of ASA Overdose (5)

A
  1. ABC’s
  2. Activated charcoal
  3. Urinary alkalinization – Use of Bicarbonate
  4. By increasing urinary pH to greater than 8, ASA gets trapped in tubes and cannot be reabsorbed
  5. Dialysis for severe acidemia, volume overload, pulmonary edema, cardiac or renal failure, seizures, coma, levels >100mg/dl in acute ingestion, or > 60-80 mg/dl in chronic ingestion
26
Q

Disposition for ASA overdose (4)

A
  1. Pt. gets charcoal and remain asymptomatic after 6-8 hours =
  2. Possible D/C
  3. Sustained release requires longer observation period
  4. Pts. with toxic levels, symptomatic, or develop symptoms = Admission
27
Q

Acetaminophen Overdose (3)

A
  1. Usually metabolized almost entirely in liver where it is converted to nontoxic form
  2. Excreted in urine
  3. Severe toxicity in adolescents in doses as low as 10-15 grams
28
Q

Acetaminophen Overdose Epidemiology (3)

A

a. Accidental overdose in children over 6
b. Adults and adolescents more likely to develop toxicity
c. Peak level 4 hours post ingestion

29
Q

Rumack-Matthew Nomogram (4)

A
  1. Sensitive predictor of hepatotoxicity
  2. Failure rate approaches zero over the past 25 years of use
  3. Useful only with levels obtained between 4 - 24 hours post ingestion
  4. Single acute ingestion
30
Q

Signs and Symptoms of Acetaminophen Overdose (5)

A
  1. Initially asymptomatic
  2. Malaise, nausea, vomiting

Liver injury:

  1. Abdominal pain,
  2. Persistent vomiting
  3. Jaundice –> Appears 14-48 hours post ingestion
31
Q

Acetaminophen Overdose Treatment (3)

A
  1. GI decontamination with activated charcoal
  2. Rumack-Matthew nomogram
    a. Patients with acetaminophen levels within safety range: no RX
    b. If at 4 hours post ingestion > 150 microgram/ml need N acetylcysteine
    c. Every 4 hours
  3. Psychiatric evaluation
32
Q

Optimum timing to obtain levels: acetaminophen

33
Q

Optimum timing to obtain levels: iron

34
Q

Optimum timing to obtain levels: salicylates

Pediatric Emergencies Exam 2 (9 decks)

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