yaya Flashcards
Adult seizure abortive
- Midazolam (versed) IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg
- Lorazepam (ativan) IV: 4 mg, rpt once (0.05-0.1 mg/kg in peds)
- Diazepam (valium) IV 0.15-0.2 mg/kg (up to 10 mg), rpt once
Pediatric seizure abortive meds
- Lorazepam (Ativan) 0.1 mg/kg IV (max 4 mg) if IV/IO access
- Diazepam (valium) 0.2 mg/kg IM (max 10 mg)
No IV:
- IM midazolam (Versed): 0.2 mg/kg (max 10 mg)
- Rectal diazepam (valium/diastat): 0.5 mg/kg (max 20 mg)
Roccuronium dose and C/I
(70) 0.6 to 1.2 mg/kg
C/I when neuro exam needed, and liver pts
Airway checklist
SOAP ME
suction
oxygen
airways (age/4 +4 (-1/2 if cuffed)
Positioning
monitor/meds
ET CO2
other- bougie, VL, LMA, oral airway
H’s ant T’s (7 and 5)
Hypovolemia
Hypoxia
Hydrogen ion excess (acidosis)
Hypoglycemia
Hypokalemia
Hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade - Cardiac
Toxins
Thrombosis (pulmonary embolus)
Thrombosis (myocardial infarction)
Modified Sgarbossa criteria
OMI w LBBB
≥ 1 lead with ≥1 mm of concordant ST elevation
≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression
≥ 1 lead anywhere with ≥ 1 mm STE and proportionally excessive discordant STE, as defined by ≥ 25% of the depth of the preceding S-wave.
4 options for peds agitation
- Haldol 0.1 mg/kg IM
- Zyprexa 1.25, 2.5, 5 mg IM
- Thorazine 12.5-50 mg IM
- Versed 1-2 mg IM
Midazolam agitation dosing
5mg IM
1-2mg IV
Toxic dose of lidcoaine
w/epi: 0.7mg/kg
w/o epi: 0.5mg/kg
WOBBLER
WPW
obstructed AV
bifascicular block
brugada
LVH
epsilon wave
repolarisation - QT
Keppra loading dose
adult: 60 mg/kg IV over 10 min (Max dose: 4500 mg) (4 grams!!)
peds: 60 mg/kg IV over 10 min (Max dose: 4500 mg)
sedation drips
propofol: 5-50mcg/kg/min (20)
versed: 0.02-0.2 mg/kg/min
precedex 0.2-0.7mcg/kg/hr
Second line adult seizure abortives
- keppra 60mg/kg max 4.5g
- Phenytoin IV 18 mg/kg
- Fosphenytoin IV 20-30 mg/kg at (may also be given IM)
- Valproic acid IV 20-40 mg/kg, max 3g
Post partum hemorrhage
- pitocin: 20 IU in 1LNS
- misoprostol /cytotec: 600 or 1000 rectal
- consider TXA 1g
Ketamine sedation dose
1-2 mg/kg (150)
Etomidate dose
0.2-0.4 mg/kg (20)
Propofol RSI dose
1.5mg/kg (100)
Succinylcholine dose and C/I
1.5mg/kg (100mg)
C/I hyperK, burns, neuromuscular disorders
Code stroke activation
LKW <4.5 with neuro deficit
LKW 4.5 - 24 hours, FANG-D positive- field cut, aphasia, neglect, gaze preference, dense hemiparesis
RBBB EKG
Positive QRS in V1
RSR’ in V1 and V2 with R’ > R
V6 with slurred terminal negative S wave
Slurred S wave in lead I, aVL, V5, and V6 (Depolarization moving away from these leads
(Depolarization moving toward these leads) (bunny ears/M shape)
LBBB EKG
Deep Negative QRS in V1
Tall notched S wave in V6
Ketamine agitation dose
4-5 mg/kg IM, max 500
(try 300)
severe asthma exacerbation
- continuous albuterol: <35 kg 10 mg/hr, >35kg 20
- 125 methylpred or 10 dex (0.6mg/kg kids)
- Mag 2 gm
Warfarin reversal dosing
PCC (1500 to 2000 units generally)
- INR 2-4: 25 units/kg
- INR 4-6: 35 units/kg
- INR >6: 50 units /kg
+ vit K 10mg IV
Analgesia drips
fentanyl 0.7-10 mcg/kg/hr
hydromorphone 0.5-3mg/hr
Pediatric dextrose containing fluids
Infant: D10, 5cc/kg IV (neonate- 2cc/kg)
Toddler: D25, 2cc/kg
Adolescent: D50, 1cc/kg
- Glucagon —
peds < 20 kg 0.5 mg
> 20 kg or adult 1 mg IV or IM - Sulfonylurea overdose: Octreotide 100 mcg IV, then 50 mcg subQ q6h
MI criteria
New ST Elevation in the J point of at least 1mm in two contiguous leads (except for V2-3)
New ST Elevation at the J point in V2-3 of at least two contiguous leads
≥2mm in men (2.5 in men <40)
≥1.5mm in women
Ekg distributions and reciprocal leads
Anterior/Septal
V1-V4
II, III and AVF
Lateral
V5-6, I and AVL
II, III and AVF
Inferior Leads
II, III And AVF
I and AVL
Posterior
V7, V8 and V9
V1-V4
Pediatric: trauma blood dose
10-20cc/kg
Pediatric hypertonic dose
3-5cc/kg
Peds trauma TXA dose
< 12, 15mg/kg
> 12, 1g
Pediatric ancef dose
17-30mg/kg
Meningitis treatment
<1 mo: amp and gent
1mo-50yo: rocephin and vanc
>50: vanc, rocephin, amp
Healthcare associated: cover pseudomonas with cefepime, mero, ceftazidine + vanc
Most to least: strep pneumo, n meningititis, h flu, listeria
Factor Xa inhibitors, MOA, reversal
Prevent prothrombin to thrombin
Apixiban//eloquis
Rivaroxaban//xarelto
4F PCC, 25-50u/kg or 2,000 u
LMWH drugs, MOA and reversal
Enoxaparin//lovenox
bind to antithrombin which inactivates Xa
Protamine: 1mg/100u heparin, max 50mg
medications for acute angle closure glaucoma
pilocarpine and timolol, alternate
IV acetazolamide
Pilocarpine (constricts)
timolol and acetazolamide (Decrease production)
Fascicular blocks
LBBB splits into LAF and LPF
- LAFB: left axis deviation
- LPFB: right axis deviation
LAFB vs LPFB
LAFB:
LAD
small q wave in I and AVL
small r in II, III and avF
intrinsicoid deflection in aVL
LPFB:
RAD
small r in I and AvL
small q in II,III and avF
intrinsicoid deflection in avF >45sec
WPW tachydysrythmia treatment
Procainamide 100mg q5m max 17mg/kg
Synchronized cardioversion
Le Fort fractures
One: separation of the hard palate from the upper maxilla due to a transverse fracture running through the maxilla and pterygoid plates at a level just above the floor of the nose
LeFort II fractures transect the nasal bones, medial-anterior orbital walls, orbital floor, inferior orbital rims and finally transversely fracture the posterior maxilla and pterygoid plates.
LeFort III fractures result in craniofacial disjunction. This is the highest level LeFort fracture and essentially separates the maxilla from the skull base.
Toxic dose of acetaminophen
150cc/kg
therapeutic: 15cc/kg
toxic dose at 4 hours 150
dose NAC 150
STEMI equivalents (4)
Posterior STEMI
LBBB or ventricular paced rhythm with scarbossa
de winters
hyper-acute T waves (broad)
de winters sign
Stemi equivalent
tall prominent, symmetrical t waves arising from uplosping ST segment depression >1mm at J point in precordial leads
may see elevation in aVR
Indications for cath in NSTEMI
- refractory angina
- hemodynamic instability
- electrical instability (VT/VF)
- signs or symptoms of HF
Anticholinergic toxicity
Red, blind, retention, hot and dry
TCA, antihistamines, atropine
TCA ekg toxicity
Sodium channel blockade + anticholinergic
QRS prolongation with terminal r wave in AvR
Sodium bicarbonate infusion
Calcium chloride
Vs
Gluconate
Chloride: 1g IV generally, central unless peri code
Gluocnate: 3g ish, more tissue necrosis
Code acronym
A- airway
B- bagging/ventilation
C-cpr, backboard!
D- defib, pads!
E- Epi
Epi dosing
Anaphylaxis:
0.01 mg/kg of 1:1,000 concentration (ie 0.5mg for 50 kg)
Code:
1 mg = 10 mL of 1:10,000 concentration
Dirty Epi drip
Amp of Epi, inject 1 mg into 1L bag= 1mcg/mL
- start at 1mcg/ min and titrate
which beta blockers cause EKG changesm (4)
Propranolol- Na channel blockade, QRS
Sotalol - K blockade, QT prolonged
Carvedilol and acebutalol- Na channel blockade
Antitodes to Acetampinophen
- NAC: 150mg/kg IV then 15mg/kg/hr x23 hours (or 140mg/kg po load)
- Fomepizole: if cross product >10,000 - - give 15mg/kg (blocks cytochrome 2E1)
Vit K
5 treatments for CCB and BB overdose
- charcoal
- atropine
- Calcium (CCB)
- glucagon
- high dose insulin (ccb>bb)
Anti-arrhythmic Drug class
I: Na channel blocker
II: beta blocer
III: K channel blockade - prolongs APD
IV: CCB
metabolic and laboratory changes with aspirin
EARLY respiratory alkalosis
metabolic acidosis- lactate and ketones
- hypokalemia
- hypoglycemia (very early hyperglycemia)
- falsely elevated chloride
- elevated INR
aspirin treatment (A-G and K)
A: alkilinization- BICARB: goal urine pH 8: a few amps bicarb and then 3 amps in 1L with 40 KCl
B: breathing is fast, avoid intubation
C: charcoal - bezoars possible
D: dialysis
E: electrolytes: K >4
F: frequent labs
G: hypglycemia
K: Vit K if INR >2
Sulfonylurea toxicity management
- blocks K channels in pancreas -> insulin release regardless of BG
- ends in “ide” - glipizide, glimeperide
- one pill can kill peds
OCTREOTIDE 50-100mg SC
Anticholinergic toxidrome
mad, blind, red, hot, dry
benadryl
cholinergic toxicity
dumbells- diarrhea, urination, miosis, bradycardia, emesis, lacrimation, lethargy, salivation
pesticides
diphenhydramine effects
antimuscarinic effects, it can produce blurred vision, dry mouth, urinary retention, tachycardia, nausea, and constipation. EKG changes can occur including widening of QRS from sodium channel blockade and tachycardia.
metformin OD management
- causes lactic acidosis via inhibition of gluconeogenesis and mitochondrial complex
charcoal
bicarb
HD (decreased mortality if dialysis <6 hrs)
Toxic alcohol management, indications, dosing (4)
Fomepizole
Osm Gap / HAGMA with toxic alcohol >20 or high suspicion
15 mg / kg followed by 10 mg/kg q12h
NaHCO3 (most useful in methanol)
Folic acid (methanol)
Thiamine (B1) and pyridoxine (B6) and Mg (ethylene glycol)
HD: definitive
ethylene glycol presentation
intoxication with more rapid (RENAL) elimination
- nephrotoxicity
- urine fluorescence
- lactate gap (False VBG lactate)
Antifreeze
isopropyl alcohol presentation
ketosis without acidosis
significant inebriation with AMS, resp depression, obtunded
methanol vs ethylene glycol vs isopropyl alcohol
methanol: windshield wiper fluid, AGMA, mild and prolonged intoxication, snowfield vision
ethylene glycol: antifreeze, AGMA, quicker and renally elimination intoxication
isopropyl alcohol: rubbing alcohol, ketosis without acidosis, obtundation
3 mechanisms of CO
- hgb shift to left
- myoglobin binding- decreased cardiac contractility
- displaces NO -> hypotension
MOA CN toxicity
sudden collapse in fire -> from burning of furniture
blocks cytochrome oxidase -> lactic acidosis
options for management of CN
Hydroxycobalamin (cyanokit): standard, more severe cases
Hydrogen cyanide kit: amyl nitrate, sodium nitrite and sodium thiosulfate (traditionally - but causes methemoglobinemia and worsens hypotension)
Nithiodote: amyl nitrate, sodium nitrite and sodium thiosulfate
Sodium thiosulfate- only option available or for less severe cases
Presentation of Dig toxicity
Nonspecific: fatigue, confusion, N/V, HA, anorexia
CARDIAC: anything, bradycardia, heart block, v tach, hypotension
Pathognomonic - bidirectional V tach
EKG finding of TCA overdose
widened QRS
terminal R wave in avR
MOA, presentation, treatment methemoglobinemia
Fe2+ -> Fe 3+ -> left shift and thus functional anemia and los SpO2
methylene blue reduces it: 1-2 mg/kg over 5 min
Intranasal fentanyl
- dose
- onset
1-2mcg/kg
Max 100 mcg
10-15 min
Intranasal versed anxiolysis
- dose
- onset
0.2-0.3 mg/kg
Max 10mg
5-10 min
Intranasal ketamine, sub dissociative
- dose
- onset
- 1-1.5 mg/kg
Max 100-200mg - 5-10 min
Cath lab activation criteria
1- STE in continuous leads
2- posterior stemi
3- LBB or RV paced with revised sgarbossa
4- de winter
5- nstemi with pain, hd or electrical instability, or HF
Lidocaine dosing
1 mg/kg upfront with redosing at 0.5mg/kg for max 3mg/kg. can follow with infusion of 1-4mg/min
Metoprolol dosing
Metoprolol 5 mg IV over 2 minutes, repeat every 5 min for max 3 doses
Diltiazem dosing
0.25 mg/kg IV over 2 minutes. Repeat in 15 min at 0.35mg/kg if ineffective
Digoxin dosing
0.5mg IV push, repeat 0.25mg every 30-60 min
MOA and pros/cons Buprenorphine vs Methadone
BUP: partial agonist, can induce withdrawal (>48 hours last dose, if already withdrawing and it worsens may jsut need larger dose), less frequent outpt care
Methadone: antagonist, QTc prolonging, daily clinic visits for a while, no withdrawal
