UW Flashcards
iron poisoning - manifestation
- within 30 mins to 4 days: abd pain, hematemesis, melena, hypotensive shock, met acidosis
- within 2 days: hepatic necrosis
- within 2-8 wks: pyloric stenosis
iron poisoning - diagnosis
- radiopaque pills
2. anion gap met acidosis
iron poisoning - treatment
1 .whole bowel irrigation
- deferoxamine (chelation)
- supportive care for circulation, airway and breathing
radiopaque poisons on the stomach
- iron
2. lead
caustic ingestion - clinical features
- laryngeal damage: hoarseness, stridor
- esophageal damage: dysphagia, odynophagia
- gastric damage: epigastric pain, bleeding
NO ALTERNATION OF CONSCIOUSNESS
caustic ingestion - management
- ABC
- decontamination, remove contaminated clothings + visible chemcals, irrigate exposed skin
- chest x-ray if resp symptoms
- endoscopy within 24 h
- upper GI x-ray with water soluble contrast in suspected perforation
caustic ingestions - complications
- Upper airway compromise
- perforation
- strictures/stenosis (2-3 wks)
- ulcers
- cancer
most reliable and predictive sign for opioids toxicity
Low RR
clinical presentation of methemglobinemia - history
exposure to oxidizing substance (eg. dapsone, nitrates, loca/topical anesthetics)
clinical examination of methemoglobinemia - clinical examination
- cyanosis
- pulse oximetry saturation 85%
- dark chocolate - colored blood
methemoblobinemia - labs findings
- saturation gap (more than 5% difference between O2 saturaton on pulse oxymetry + ABG)
- Normal Pa02
methemoglobinemia - plasma osmolar gap
normal
methemoglobinemia - treatment
Methylene blue is the antidote for symptomatic methemoglobinemia or high levels of methemoglobin
(also vit C)
lead poisoning in adults - RF
occupational exposure (eg. ;lead paint, batteries, ammunition, construction)
Lead poisoning - clinical featurres
- GI (abd pain, constipation, anorexia)
- neurologic (cognitive deficits, peripheral neuropathy)
- hematologic (anemia)
lead poisoning in adults - labs
- anemia
- elevated venous lead level
- elvated serue zinc protoporhyrin level
- basophilic stippling on peripheral smear
arsenic poisoning - mechanism
binds 1. to sulfhydryl groups
2. disrupts cellular respiration + gluconeogenesis
arsenic poisoning - sources
- pesticides / insecticides
- contaminated water (often from wells)
- pressure treated wood
arsenic poisoning - manifestation
- acute: garlic breath, vomiting, watery diarrhea, WTc prolongation
- chrnic: hypo/hyperpigmentation/ hyperkeratosis/ stocking-glove neruopathy
- also pancytopenia, mild elevation of liver enzymes
arsenic poisoning - treatment
- dimercaprol
2. DMSA (meso-2,3 dimercaprosuccinic acid, succimer)
clinical features of hypothermia
- mild (32-35): tachycardia, tachypnea, ataxia, dysarthria, increased shivering
- moderate (28-32): bradycardia, lethargy, hypoventilation, decreased shivering, atrial arhythmias
- severe (under 28): coma, cardiov collapse, ventricular arrhythmia
hypothemia - general treatment
- warmed (42) crystalloid for hypotension
- endotracheal intubation in comatose patients
hypotermia - treatment for mild (32-35)
passive external warming (remove wet clothing, cover with blankets
hypothermia - treatment for moderate (28-32)
active external warming (warm blankets, heating pads, warm baths)
hypothermia - treatment for severe (under 28)
active internal rewarming (warmed pleural or peritoneal irrigation, warmed humidivied oxygen)
bradycardia of hypothermia
- refractory to pacing or atropine
- treat hypothermia
Benzo - resp depression if
with other substance (opioid, alcohol) or if IV
CNS toxicity of TCA
- mental status changes
- seizures
- resp depression
Cardiovascular toxicity of TCA
- sinus tachycardia, hypotenesion
- prolonged PR/QRS/QT
- arrhythmas (VT, VF)
anticholinergic effects of TCA
Dry mouth, blurred vision, dilated pupils, Urinary retention, flushing, hypertehermia
TCA overdose - management
- O2 / intubation
- IV fluids
3. activated charcoal within 2 hours (unless ileus present) - IV sodium biocarbonate for QRS or ventric arrhythmia (IF QRS MORE THAN 100)
major products of poisoning in fires
- CO
2. Cyanide
treatment of cyanide toxicity - generally
- decontamination
- Resp support
- cardiovascular support
cyanide poisoning - decontamination
derma; exposure: removal of clothing, skin decontamination
- ingestion: activated charcoal
- all exposures: antidote: hydroxycobolamin preferred, sodium thiosulfate (alternative), if antidote not availble (nitrates)
cyanide poisoning - resp support
- no mouth to mouth resuscitation
- supplemental oxygen
- airway protection
cyanide poisoning - cardiovascular support
IV fluids in hypotension
methanol intoxitation - most severe consequences
vision loss + coma
methanol intoxication - physical exam
optic disc hyperemia
methanol intoxitation - labs
anion gap metabolic acidosis
- increased osm gap
ethylen glycol vs methanol poisoning
- both are ingested as a substitute for ethanol and both can cause anion gap met acidosis + increased osm gap
- methanol damages eyes, ethylene glycol damages kidneys
opioid intoxication - miosis
its absence does not exclude the diagnosis. Normal or even enlarged pupils may be seen in patients who have co-exposures to other agents that can counteract miosis
- the most reliable sign is low RR
acetaminophen intoxitation - management
single dose 7.5g ore more (pediatric 150mg.kg)?
YES –> if less than 4 hours give charcoal –> check acetaminophen levels
NO (or indeterminate) –> if chronic ingestion check acetaminophen levels
after levels –> if above treatemtn line in nomogram or more than 10μg/ml if timing of ingestion unclear or any evidence of liver injury –> administer N. acetylysteine + monitor for liver injury
NaHCO3 mechanism as an antidote of TCA
increases serum ph and extracellular sodium –> alleviating the cardio-depressant action of Na2+ channel
pink red skin?
carbon monoxide or Cyanide tox
lead poisoning - management
- obtain venous sample (if screening perfomerd by capillary sample)
- enviromental surveilance (identify + remove lead sources)
- notify public health department
- nutritional counseling
- chelation therapy if lead level more than 45
opioid withdrawal - management
opioid agonists: methadone (preferred) or buprenorphine
- nonopioid: clonidine or adjunctive medication (antiemetics, antidiarrheals, benzodiazepines)
CO poisoning - epidemiology
- smoke inhalation
- defective heating systems
- motors operating in poorly ventilated areas
CO poisoning - manifestations
- mid-moderate: headache, confusion, malaise, dizziness, nausea
- severe: seizure, sycope, coma, MI, arrhthmias
CO poisoning - treatment
high flow 100% O2
2. intubation/hyperbaric O2 therapy (if severe)
management of anticholinergic overdose
pysostigmine (cholinestarase inh)
toxic alcohols - types
- alcohol ketoacidosis
- methanol ingestion
- ethylene glycol ingestion
- isopropyl alcohol ingestion
alcohol ketoacidosis - clinical features
slurred speech, unsteady gait, altered mentation
alcohol ketoacidosis - labs
- high osmolar gap
2. increased anion gap metabolic acidosis
methanol ingestion - clinical features
visual blurring, central scotomas, afferent upillary defect, altereled mentation
methanol ingestion - labs
- high osm gap
2. increased anion gap metabolic acidosis
ethylene glycol ingestion 0 clinical features
- flank pain, hematuria, oliguria
- CN paliseis
- tetany
ethylene glycol ingestion - labs
- high osm gap
- increased anion gap metab acidosis
- calcium oxalate crystals in urine
isopropyl alcohol ingestion - clinical features
- CNS depression
- disconjugate gaze
- absent ciliary reflex
isopropyl alcohol ingestion - labs
- high osm gap
2. no increased anion gap or met acidosis
chemicals in the eye - best primary course
flush the eye with water - best achieved under a faucet of ranning water for at least 15 minutes (1st water and then medical care vs cut scratches or foreign bodies)
caustic ingestion - charcoal
NO:
- caustic cause damage on the GI (not systemic)
- charcoal is contraindicated as it will obstruct the view during endoscopy
frostbite - clinical findings
- superficial pallor + anesthesia
- blistering, eschar formation
- deep tissue necrosis + mummification
frostbite - management
- rapid rewarming in 37-39 C IN WATER BATH (NOT HOT AIR)
- analgesia + wound care
- thrombolysis in severe, limb threatening cases
attempt of suicide with unknown pill - most appropriate next step
gastric lavage
gastric lavage - dangerous in … (and why)
- altered mental status: may cause aspiration
- caustic ingestion: caustic ingestion: causes burning of the esophagus and oropharynx
- acetaminophen overdose (delay the administration of overdose - N-acetylcysteine)
pills ingestion - whole bowel irrigation
- placing a gastric tube and flushing out the GI tract with polythylene glycol-electolyte solution (GoLYTELY: Braintree Laboratories, Braintree Massachusetts) is always wrong.
- indications are very narrow and limited to massive iron ingestion, lithium and swallowing drug-filled packets (eg. smuggling)
whole bowel irrigation - indications
- massive iron ingestion
- lithium
- swallowing drug-filled packets (eg. smuggling)
attempt of suicide with unknown pill and altered mental status - most appropriate next step
naloxone and dextrose
overdose - opiate vs benzodiazepine management
opiate overdose is fatal –> give naloxone immediately
benzodiazepine is not –> acute withdrawal causes seizures. DO NOT give flumazenil
pills overdose - charcoal
- should be given to anyone with a pill overdose
- may not be effective for every overdose, but it never dangerous
- remove toxic substance even after they have been absorbed
- blood levels of toxins drop faster in those given repeated doses of charcoal
- it is superior to lavage and ipecac
acetaminophen and alcohol
alcoholism decreases the amount of acetaminophen needed to cause toxicity
aspirin overdose can cause … (severe situation)
ARDS
MCC of death in fires
CO: 60% of deaths on the first day after a fire
CO poisoning death due to
MI
CO vs methemoglobinemia according to blood color
CO –> red
Methem –> brown
methemoglobinemia diagnosis
- normal pO2
- the most accurate test is methemoglobin level
cyanosis + normal p02 = ….
methemoglobinemia
organophosphate (insecticide) poisoning and Nerve gas - absorbed through
skin
digoxin toxicity - etiology
- hypokalemia predisposes to digoxin toxicity (K+ and digoxin compete for binding at the same site on the pump –> less K+ more digoxin is bound
- renal failure –> decreased excretion
Rhythm disturbance of digoxin toxicity
ANY ARRHYTHMIA
bradycardia, Atrial tachycardia, AV block, ventricular ectopy, AF with slow rate
Atrial arrhythmia with variable AV block is the MC
mercury toxicity - presentation
orally ingested –> neurological problems: nervous, jittery, twitchy, sometimes hallucinatory
inhaled –> lung toxicity: interstitial fibrosis
methanol vs ethylene glycol - source
methanol: wood alcohol, cleaning solutions, paint thinner
ethylene glycol: antifreeze
osmolar gap?
the difference between the measured serum osm and calculated osm
if u calc serm osm 300 but on measurement u find 350, it is possible that a toxic alcohol such as methanol or ethylene glycol is accounting for the extra osmoles
Ordinary alcohol (ETHANOL) also increases the osm gap
methanol vs ethylene glycol - treatment
the best initial is fomepizole (inhibits alcohol dehydrogenase and prevents production of the toxic metabolie) –> it does not remove the substance from the body
Only dialysis will effectively remve methanol and ethylene glycol from the body
beneficial therapy of snake bites
- pressure
- immobilization decreases movement of venom
- antivenin
ineffective or dangerous treatment
- tourniquets blocking arterial flow
- ice
- incision and suction, esp bu month
dog, cat and hyuman bites - microbes
dogs and cats: Pasteurella mustocida
humans: Eikenella corrodens
warning rate in hypothermia - target
1-2 C/hour
how to confirm CO poisoning
elevated HbCO:
- more than 3% in nonsmoker
- more than 10% in smoker
standard oxymetry is unreliable
source of cyanide
burning of rubber or plastic (NOT WOOD)
a characteristc of inhaled cyanide
bitter almond breath
lead poisoning - emergency vs non emergency
- succimer: 45-69
2. dimercaprol plus EDTA on emergency, more tha n70, or acute encephalopathy
toxic alcohols - types and clinical features
- alcohol ketoacidosis: slurred speech, unsteady gait, altered mentation
- methanol ingestion: visual blurring, central scotomas, afferent pup defect, altered mentation
- ethylene glycol ingestion: flank pain, hematuria, oliguria, CNS palsy, tetany
- isopropyl alcohol ingestion: CNS depression, disconjugate gaze, absent ciliary reflex
toxic alcohols - types, which of them has high osm gap
- alcohol ketoacidosis
- methanol ingestion
- ethylene glycol ingestion
- isopropyl alcohol ingestion
high osm gap in all
toxic alcohols - types, which of them has increased anion gap met acidosis
- alcohol ketoacidosis
- methanol ingestion
- ethylene glycol ingestion
- isopropyl alcohol ingestion
only isopropyl alcohol ingestion does not have
