1) The document provides an overview of shock, including common clinical features, key hemodynamic parameters, and types of shock. It also reviews vasopressors commonly used to treat shock.
2) Emergency disorders in critical care are reviewed, including acute inhalational injuries, anaphylaxis, hypertensive emergencies, hyperthermic emergencies, hypothermic emergencies, and toxicology. Management strategies for these conditions are discussed.
3) Case examples are provided to demonstrate assessment and treatment of patients presenting with septic shock, acute liver failure, and altered mental status, and the appropriate next steps in management are outlined.
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The presentation covers basics of pharmacotherapy involves in advanced life support scenario including peri-arrest situations which have been updated 2019
Rational choice of inotropes and vasopressors in intensive care unitSaneesh P J
The presentation introduces commonly used interpose and vasopressors; their classification; and how to choose the drug in ICU. Clinical scenarios - cariogenic shock; neurocritical care; septic shock and anaphylactic shock are elaborated.
Join live classes, download study aids, sell your documents, join or host your own classes online, get tutoring, tutor students, take practices tests and more at Examville.com
The presentation covers basics of pharmacotherapy involves in advanced life support scenario including peri-arrest situations which have been updated 2019
Rational choice of inotropes and vasopressors in intensive care unitSaneesh P J
The presentation introduces commonly used interpose and vasopressors; their classification; and how to choose the drug in ICU. Clinical scenarios - cariogenic shock; neurocritical care; septic shock and anaphylactic shock are elaborated.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
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This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
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Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
2. Shock
Decreased tissue perfusion
inadequate O2 delivery tiessue
ischemiaCommon Clinical Features of Shock
1. HYPOTENSION
SBP < 90 mm Hg
MAP <60 mm Hg
Acute decreased in SBP of > 40 mm Hg
Lack of MAP response to initial fluid challenge
2. END_ORGAN DYSFUNCTION DUE TO HYPOPERFUSION
Decreased urine output
Change in mental status
Increased serum lactic acid level
4. Blood
Pressure
Cardiac output
(decreased in cardiogenic
shock)
Systemic Vascular Resistance
(decreased in distributive shock)
Heart Rate Stroke Volume
Preload
(decreased in
hypovolemic shock)
Contractility Afterload
5. Type of Shock Decreased
parameter
Example
Cardiogenic Cardiac output Acute heart
failure, massive
pulmonary emboli
Distributive Systemic vascular
resistance
Sepsis,
anaphylaxis
Hypovolemic Preload Acute
hemorrhage,
severe
dehydration
6. Agent
(dose)
Receptors Clinical Use Common Side
Effects or
Contraindications
Norepinephrin
e
a1 > B1
First line in
septic shock
Some arrhythmias, digital
ischemia
Dopamine
(low)
DA >B1
Historically used
fir kidney failure
(no evidence of
effectiveness
Highest arrhythmia risk
and ischemia
Dopamine
(medium)
B1> B2
Septic or
cardiogenic
shock
Dopamine
(high)
a1 > B1
First line in
septic shock
Epinephrine
(low)
B1> B2
Second line for
septic or
cardiogenic
shock
Arrhythmias and
ischemia
Epinephrine
(high)
a1 = B1
Second line for
septic shock
phenylephrine a1
Milder shock
states, least
risky through
peripheral IV
Lowest arrhythmia risk,
not as powerful as other
vasopressors
Vasopressin Vasopressin Second Splanchnic ischemia, no
7. A 71M is evaluated in the ED for septic
shock secondary to a UTI.
On P/E, he is lethargic and confused.
Vitals: T: 101.3, BP: 80/35, Pulse: 122/min,
RR: 23
Right CVA ttp is noted.
Labs: hematocrit: 33%, WBC: 15600
UA: innumerable leukocytes and gram
negative bacteria.
Blood and urine culture results are
pending.
8. Which of the following should be
accomplished in the next hour?
a) Attain hematocrit greater than 35%
b) Begin low-dose dopamin
c) Initiate antibiotic therapy
d) Insert a pulmonary artery catheter
9. Empiric antibiotic therapy should be
initiated whithin 1 hour of recognition
of sepsis after cultures have been
taken from the blood and other
suspected sites of infection.
(#timetoantibiotic)
10. A 41F is admitted to the ICU for a 1-day hx of
progressively worsening AMS and jaundice. Her MHx is
significant for autoimmune hepatitis dx’ed 10 yrs ago.
On P/E:
Vitals: T: 91.4, BP: 105/55, pulse rate: 110/min, RR:
27/min; BMI: 18
She is unresponsive to sternal rub and is jaundiced. The
lungs are clear and cardiac examination is normal.
Abdominal examination reveals a distended abdomen
with a detectable fluid wave. The extremities are WWP.
Lab: WBC: 9800, Cr: 1.6, lactic acid level: 6 – UA:
unremarkable. Blood and urine culture results are
pending.
Imaging: CXR: nl
IVF and epiricbroad-spectrum antibiotics are begun.
11. Which of the following is the most
appropriate next step in management?
a) Abdominal CT
b) Diagnostic paracentesis
c) Dopamine
d) Hydrocortisone
12. The primary goals of sepsis
management are infection source
control and early antibiotics
13. A 78F is treated in the ICU for a 24-hr hx of AMSthat has
been progressively worsening. She is a resident of a nursing
home, and her MHx is significant for Alzheimer disease.
On arrival to the ED, she was disoriented, febrile, tachycardic
with a HR of 115/min, and hypotensive with a BP of 82/40.
Labs:
WBC: 33,000 – hemoglobin: 11 – urine dipstick was positive
for nitrites and leukocyte esterase. – Blood and urine culture
results are pending.
Imaging:
CXR: normal
Central access was obtained and she was started on broad-
spectrum antibiotics. A 1000-ml normal saline fluid challenged
was administered over 30 minutes.
Current examination in the ICU shows the patient to have an
unchanged mental status. BP is now: 85/45 mm Hg and HR:
100/min. Her P/E is unchanged
14. Which of the following is the most
appropriate immediate next step in
management?
a) Erythrocyte transfususion
b) Hydrocortisone
c) Norepinephrine
d) Normal Saline at 200 ml/h
15. Vasopressor therapy is indiacted to
maintain a MAP of greater than or
equal to 65 mm Hg or CVP
measurement of 8-12 mm Hg in
patients with sepsis who have failed to
respond to an initial crystalloid fluid
challenge.
17. Acute Inhalational Injuries
Burn victims
Approximately half of deaths associated
with with burns are due to complications
of inhalational injury
When the inhalational exposure is brief
and the inhaled toxins are water soluble
tissue damage is greates in the
proximal airways
When inhalational injuries include less
water-soluble toxins or prolonged heat
exposure damage can extend into
distal airways and lung parenchyma
18. Complications: pulmonary edema,
airway stenosis, RADS,
bronchiolitisobliterans,
bronchiectasis and parenchymal
fibrosis
CO, Cyanide toxicity common in
smoke inhalation
Burn victims at high risk of
secondary infections: staph,
pseudomonal
19. Supportive Care of patients with
Acute Inhalational Injuries:
IV fluids
Intubation for mechanical ventilation
Chest physiotherapy
Bronchoscopic debridement and
suctioning
Inhaled racemic epinephrine
Antibiotics
23. Management of Anaphylaxis:
O2 and IV fluids
Epinephrin (SQ or IM) – higher doses or
continuous for patients on BBs
Antihistamines or coticosteroids (strong
evidence is lacking)
Inhaled bronchodilators reduce
bronchospasm and airway edema
Airway support
With timely supportive care, anaphylaxis
is rarely fatal
24. Hypertensive Emergencies
Episodes of elevated BP associated
with end-organ damage
Men, black patients and elderly
patients with poorly controlled
essential hypertension
CNS (presenting with stroke in 25%),
renal (AKI), cardiovascular (ischemic
chest pain or acute heart failure)
25. BP should be measured in both arms
and in both supine and standing
positions
A careful neuro exam including mental
status and visual fields and acuity
Lab studies: CBC, BMP, cardiac
biomarkers, UA, drug levels including
cocaine and amphetamines
EKG, CXR, brain imaging (AMS, neuro
findings suggestive of stroke)
Aortic dissection is always a possibility
(CT-angio, TEE)
26. BP should be lowered by no more
than 25% initially
Systolic and diastolic targets over the
next 2-6 hours: 160/110 with gradual
correction after that
27. Agent (Class) Notes Adverse Effects
Nitroprusside
(vasodilator)
Easy to titrate; often
1st choice for acute
situations
Risk for cyanide
toxicity
NTG (vasodilator) Used for MI; tolerance
develop
Headache,
bradycardia
Hydralazine
(vasodilator)
Safe in pregnancy Nausea, headache
and tachycardia
Labetolol (alpha and
beta blocker)
Can be switched to
oral
Bradycardia, heart
block, nausea,
bronchospasm
Enalaprilat (ACEI) Can be switched to
oral; good for LV
failure
Prolonged
hypotension
Nicardipine (CCB) Often used for patients
with stroke
MI, tachycardia,
headache
Fenoldopam
(dopamine agonist)
Can be titrated up
slowly; may be
protective of kidneys
Flushing, headache,
nausea, tachycardia,
possibly increased MI
Phentolamine (alpha
blocker)
Used for dx of and
surgery for
Nausea, arrhythmia
28. Hyperthermic Emergencies
A rise in core body temperature > 40
C (104.0 F)
Clinical features: AMS (including
seizures), muscle rigidity, and
rhabdomyolysis (with kidney failure) –
severe cases: DIC, ARDS
Heat stroke
Malignant hyperthermia
Neuroleptic malignant syndrome
29. Heat Stroke
Failure of the body’s thermoregulatory
system
Impaired thermoregulation: elderly and
patients treated for conditions that
lead to dehydration and anhidrosis
Overwhelmed thermoregulation:
athletes and military recruits who are
required to exercise strenuously in hot
and humid weather
30. Patients should be cooled to lower
their core body temperature
Do not respond to centrally acting
antipyretic medications
Evaporative cooling methods and ice
packs are usually most effective
In severe cases, cold gastric or
peritoneal lavage may be attempted
BZD decrease discomfort and
shivering during these treatments
31. Malignant Hyperthermia
Reaction to certain classes of drugs
including inhaled anesthetics
(halothane and others) and
depolarizing neuromuscular blockers
(succinylcholine and decamethonium
[syncurine])
Markedly increased intracellular
calcium increased cellular
metabolism sustained muscle
tetany
Susceptibility to malignant
hyperthermia is inherited
32. Severe muscle rigidity, masseter
spasm, hyperthermia with core T up to
45, cardiac tachyarrhythmias, and
rhabdomyolysis are common manifestations.
Mortality rate: 10%
Triggering agent should be stopped
Fluids and cooling methods should be
initiated
Dantrolene is given q 5-10 min until
hyperthermia and rigidity resolve
Dantrolene can also prevent recurrence in
patients with a hx of malignant hyperthermia
if given before administration of the triggering
agent
33. Neuroleptic Malignant
Syndrome
Idiosyncratic reaction to neuroleptic
antipsychotic agents
Characterized by muscle rigidity,
hyperthermia and autonomic
dysregulation
Delirium is common
Potent “typical” neuroleptics are most
commonly implicated
Often occurs after medication is started
or uptitrated – it occasionally occurs after
years of problem-free use
Concomitant Li use may be a risk factor
34. Mortality rate: 10-20%
Treatment include: stopping the
neuroleptic agent, maintaining BP
stability, IVF, lowering the elevated
T, BZD for agitation
Dantrolene and bromocriptine are also
used, but the evidence for these
agents is weak
35. Hypothermic emergencies
Core T below 35 (95 F)
Exposure to cold weather and submersion in
cold water
Causes cellular dysfunction and lyte
abnormalities, esp. hyperkalemia
Mild hypothermia [32-35 C (89.6-95 F)]
shivering, AMS, ataxia, polyuria
Moderate hypothermia [28-32 C (82.4-89.6 F)
decreased HR, CO, more severe AMS,
cardiac arrhythmias
Severe hypertormia [<28 C (82.4)]
pulmonary edema, coma, hypotension,
areflexia, ventricular arrhythmias and cardiac
arrest
36. J Wave (osborne wave)
A 47-year-old man with chronic schizophrenia was hospitalized after
prolonged hypothermia. The initial electrocardiogram revealed
Osborn waves (arrowheads) similar in amplitude to the R waves.
Characteristic sinus bradycardia and prolongation of the QRS
interval and the corrected QT interval (QTc) were also noted. During
rewarming, the Osborn waves diminished in amplitude, and they
disappeared after 24 hours. The baseline tremor artifact caused by
shivering (arrows) resolved on normalization of the patient's core
body temperature. In 1953, Dr. John Osborn described the J wave
as an “injury current” resulting in ventricular fibrillation during
experimental hypothermia. More recent findings suggest that
hypothermia increases the epicardial potassium current relative to
the current in the endocardium during ventricular repolarization. This
transmural voltage gradient is reflected on the surface
electrocardiogram as a prominent J, or Osborn, wave. The
differential diagnosis of prominent Osborn waves includes early
repolarization, hypercalcemia, and the Brugada syndrome.
37. Giant Osborn Waves in Hypothermia
Krantz MJ, Lowery CM. N Engl J Med 2005;352:184-184.
41. Effect of Fomepizole on the Pathophysiological Effects of Poisoning from Ethylene Glycol and
Methanol.
Brent J. N Engl J Med 2009;360:2216-2223.
42.
43.
44. Toxicity of Drugs of Abuse
Agent Toxic Dose
(or serum
level)
Toxic effect
or syndrome
Pharmaceuti
cal antidote
Other
interventions
Acetaminophen 7.5 g in 8 hrs Acute hepatitis,
fulminant
hepatic failure
NAC PO or IV
within 8 hrs
(may give later
as well)
Charcoal within
4 hours
BZD variable CNS and
respiraory
suppression
Flumazenil
(caution if risk of
seizures)
Ventilatory and
hemodynamic
support
BB variable Bradycardia,
heart block,
hypotension
Glucagon,
CaCl2
Transcutaneous
or transvenous
pacing
CCB variable Bradyarrhythmia
; heart block,
hypotension
Glucagon,
CaCl2
Transcutaneous
or transvenous
pacing
Digoxin Serum levels
have poor
correlation with
toxicity
Bradyarrhythmia
and
tachyarrhythmia;
chronic toxicity,
CNS and GI Sx
Digoxin-
specificAb
HEMODIALYSI
S IS NOT
EFFECTIVE
45. Toxicity of Drugs of Abuse
Agent Toxic Dose Toxic Effect or
Syndrome
Pharmaceutical
Antidote
Other
Interventions
Sulfonylureas One tablet in a
child or non-
diabetic patient
may cause
hypoglycemia
Hypoglycemia
and related Sx
Dextrose,
Octreotide,
glucagon for
short term while
dextrose is
delayed
Beware
recurrent
hypoglycemia
even after initial
response
Lithium Most overdoses
are chronic
(serum level
upper limit is 1.2
mEq/L for acute
mania, 0.8 mEq
for
maintenance; 3
indicates severe
toxicity)
Tremor, nausea,
polyuria, DI,
arrhythmias,
photosensitivitie
s, cardiogenic
shock due to
CNS effect
NO ANTIDOTE
FOR Li; medical
treatments for
secondary
arrhythmias,
seizures,
hypotension
Hemodialysis for
AMS, anuria or
seizures; IV fluid
hydration with
careful
monitoring of
lytes, esp in DI
Salicylates Levels > 30-40
mg/dL usually
mean clinical
toxicity; chronic
toxicity is more
common and
more dangerous
Metabolic
acidosis,
hyperventilation,
dehydration;
severe
intoxication can
cause seizure,
hypoglycemia
and lyte
abnormalities
Sodium
bicarbonate
infusionto
achieve urine
output of > 2
mL/kg/h and pH
of >8 (pH is
more important
than diuresis)
HD for severe
toxicity or poorly
tolerated
medical therapy
46. Agent Toxic Dose (or
serum level)
Toxic Effect or
Syndrome
Pharmaceutical
Antidote
Other
Interventions
Theophylline Therapeutic
range 10-
20mcg/mL, but
toxicity can
occur in this
range
Nausea,
nervousness,
CNS
stimulation,
HTN,
tachypnea,
seizures, atrial
and ventricular
arrhythmias,
hypokalemia,
hyperglycemia,
status
epilepticus
Activated
charcoal can be
given
Charcoal
hemoperfusion
is treatment of
choice, but HD
can also be
used if
hemoperfusion
is not
available;cardio
version, seizure
control, airway
management,
electrolyte
correction
TCA Levels do not
correlate well
with toxicity;
better to follow
clinical signs
and Sx
Sudden or
delayed onset of
seizures, severe
arrhythmias,
hypotension,
rhabdomyolysis,
and kidney
failure
Bicarbonate
infusion titrated
to QT interval
improvement on
EKG
HD is not
effective,
monitor and
correct lytes,
defibrillation,
pacing for
bradycardia
(avoid atropine
or
cathecholamine
s)
47. A 55M is evaluated in the ED after
being found unconscious on the
ground outside of his home by family
members. He was difficult to arouse
and was confused. He was breathing
spontaneously, but his breaths were
rapid and shallow.
P/E:
Vitals: T: 97.7 BP: 135/91, pulse
110/min, RR: 24/min
Other than tachycardia, the
cardiopulmonary examination is
normal. The abdomen is soft, no focal
findings on neuro exam
48. Labs:
BUN: 14
Cr: 1.9
Lytes: Na: 138 K: 4.1 Cl: 90 Bicarb: 12 glucose: 90
Lactic acid: 2.8
Serum osmolality 390
ABG: pH: 7.24 PCO2: 28 PO2: 102
Serum Tox: negative for ETOH, opioids, BZD and common
recreational drugs
Imaging:
CXR: no lung infiltrates or masses.
There is very little urine in the bladder, but urine obtained by
catheterization contains many erythrocytes and envelope-
shaped crystals.
49. Which of the following is the most
appropriate treatment?
a) Hemodialysis
b) Intravenous ethanol
c) Intravenous fomepizole
d) Intravenous fomepizole and
hemodialysis
e) Supportive care
50. Calculated serum osm:
2 Na + Glucose/18 + BUN/2.8 =
2 (138) + 90/18 + 14/2.8 = 276 + 5 + 5 =
376
Osmolality gap = observed – expected
Osm gap = 390 – 376 = 14
51. #classicHACadmission
A 39 yo M is admitted to the hospital for new-onset
agitation, fluctuating level of consciousness and
tremors. He is diagnosed with acute alcoholic hepatitis.
On P/E,
Vitals: T: 101.8, BP: 95/55, HR: 130 and RR: 30
Jaundice is noted. The abdomen is protuberant with
ascites, but is soft with no abdominal rigidity or
guarding. There’s no blood in stool. The patient is
agitated and disoriented, is unable to maintain attention
and appear to be having visual hallucination. He
believes that the nurse has stolen his wallet (which is in
his bedside drawer) in order to obtain his identity. He is
diaphoretic and tremulous. Asterixis is absent, and the
remainder of neurologic examination is normal.
52. Which of the following is the most
appropriate management?
a) Ceftriaxone
b) CT of the head
c) Haloperidol
d) Lactulose enema
e) Lorazepam
53. Delirium tremens is characterized by
fluctuating level of
consciousness, disorientation, reduce
d attention, global amnesia, impaired
cognition and speech and often
hallucinations and delusions.
54. A 21 yo M is evaluated in the ED for
shortness of breath after a bee sting. He
feels lightheaded and describes a sense
of puffiness in his face.
On P/E:
Vitals: T: 100.4, BP: 98/60, HR: 100 RR:
24/min
He is agitated, bilateral wheezing is noted.
There is no stridor and no evidence of
facial, tongue or oropharyngeal swelling.
There’s no rash. CXR shows
hyperinflation.
55. Which of the following is the most
appropriate treatment?
a) Endotracheal intubation and
mechanical ventilation
b) Intramuscular epinephrine and inhaled
albuterol
c) Intravenous diphenhydramine and
methylprednisolone
d) Intravenous
epinephrine, methylprednisolone, and
diphenhydramine
56. A 19-year-old woman is evaluated in
the ED after taking an overdose of
medication in an apparent suicide
attempt.
On P/E: she is intubated and on
mechanical ventilation. She is
obtunded.
Vitals: T: 100.2, BP: 96/60, HR: 92, RR
on assisted mode of ventilation:
18/min.
57. Laboratory studies reveal a plasma
glucose level of 100. Qualitative urine
toxicology screen reveals the
presence of benzodiazepines and
tricyclic antidepressants. No other
toxins are identified in her serum or
urine.
Initial EKG shows sinus tachycardia
with a QRS duration of 90 ms. – EKG
in the ICU several hours later shows a
QRS duration of 130 ms.
58. In addition to isotonic saline and
vasopressors, which of the following is
the most appropriate next step in
management?
a) Naloxone
b) Procainamide
c) Saline diuresis
d) Sodium bicarbonate infusion
60. TCA (Na-channel blocker)
Toxicity
Sinus tachycardia with first-degree AV
block (P waves hidden in the T waves,
best seen in V1-2).
Broad QRS complexes.
Positive R’ wave in aVR.
61. A 62yo M is evaluated in the ED for
headache and confusion. He does not
have chest pain or discomfort. His
medical hx is significant for essential
hypertension, transient ischemic
attack, type 2 DM (controlled by
diet), and high cholesterol. His current
medications are
HCTZ, amlodipine, aspirin
andatorvastatin.
62. On P/E:
Vitals: T: normal, BP: 220/135 (same in both arms), HR:
88, RR: 20; BMI: 31.
He is intermittently lethargic and agitated, and he’s
oriented to self and place but not date and time.
Funduscopic exam cannot be performed owing to
agitation. There is no focal weakness or loss of
sensation, the cranial nerves are intact, and the gait is
slow but otherwise normal. The lungs are clear. Pedal
edema is noted.
Labs:
Lytes, CBC, Ti, UA all normal
Imaging:
CXR: normal
CT-head w/o contrast: evidence of old lacunar infarct but
no signs of acute stroke or bleeding.
63. Which of the following is the most
appropriate initial target blood
pressure for this patient?
a) 130/80 mm Hg
b) 140/90 mm Hg
c) 185/110 mm Hg
d) 200/120 mm Hg
64. A 50yo M is admitted to the hospital
for pneumonia. He was started on
antibiotics in the ED. He has a hx of
bipolar disorder that is controlled with
Li and risperidone.
On the eveing of admission, he
becomes agitated and confused. He is
given IV haloperidol, and he develops
fever and muscle rigidity.
65. On P/E:
Vitals: T: 39.9 (103.8), BP:
187/108, pulse rate: 110/min, RR:
32/min. Diaphoresis, rigidity and
agitation are present. No stridor or
signs of respiraory failure are noted.
66. In addition to IVF therapy, which of the
following is the most appropriate initial
treatment?
a) Acetaminophen
b) Atracurium
c) Intubation and mechanical ventilation
d) Lorazepam
e) Nitroprusside
67. An 18 yo F is evaluated in the ED after being
rescued from a burning house. She was
unconscious for a few minutes at the scene
and on the way to the hospital, but she
regained consciousness in the ED.
On P/E: she is agitated but follows
commands and is oriented
Vitals: T: 99.3, BP: 145/80, pulse rate:
20/min, SaO2: 98% on RA
She coughs frequently. There are no skin
burns. No cyanosis, respiratory
stridor, sputum production, or soot around
airway orifices is noted.
69. In addition to placing the patient on
100% O2, which of the following is the
mostappropriate next step in
management?
a) Blood cyanide level measurement
b) Hyperbaric oxygen therapy
c) Intubation and initiation of
mechanical ventilation
d) Pulse oximetry
70. In patients with CO toxicity and high
levels of carboxyhemoglobin,
hyperbaric O2 therapy greatly speeds
the clearance of carboxyhemoglobin
and has been shown to reduce the
incidence of delayed neurocognitive
impairment.