6. Bites
• Rabies
– Bats, raccoons, skunks, foxes, coyotes: major carriers
• Bat exposure consists of the following: actual bat bite, exposure to
bat fluids, bat found in room where child is sleeping, bat in close
proximity to a child
– Dogs/cats can be a reservoir
– Rodents (squirrels, rabbits, rats) DO NOT usually carry rabies
(low risk)
– Observe domestic animal if not ill, euthanize if becomes ill
– Euthanize wild animal and test for rabies
– Contact health dept
– Rabies therapy
• As much of the dose as possible of rabies immune globulin (RIG)
into the wound and the rest IM
• Rabies vaccine-5 doses on Day 0, 3, 7, 14, 28 (don’t give in the
gluteus)
7. Dog/Cat Bites
• Sponge clean wounds
• Do NOT irrigate puncture wounds
• Give tetanus
• Commonly infected with pasteurella
• Abx for dog/cat/human/reptile bites
– Amoxicillin/Clavulanate
– Bactrim + Clindamycin if pcn allergic
8. Snake Bites
• 95% in US are pit vipers (crotalidae-rattlesnakes,
copperheads, cottonmouths)
– Triangular head
– Elliptical eyes
– Pit between eye and nose
• Pit viper venom
– Tissue necrosis (edema, ecchymosis, blistering)
– Vascular leak (hypotension)
– Coagulopathies
– Neurotoxicity
• Children are susceptible because of low body
mass
9. Snake Bites
• Signs/Symptoms
– Develop within 2-6 hrs
– Severe pain, N/V, weakness, muscle fasciculations,
coag abnormalities
• Treatment
– ID snake
– Immobilize extremity, wound pressure
– Avoid tourniquet unless prolonged transport time
– No ice or excision or suction
– IV lines, CBC, pain meds, tetanus
– Antivenom is available (CroFab)
10. Spider Bites
• Black Widow-up to 3 inches in size with
red/orange mark on back
– Lives in basements and garages
– Venom is a neurotoxin
– Symptoms/Signs
• Pain at site
• Muscle cramping
• Chest tightness
• Vomiting
• Sweating
• Abdominal pain
• Agitation
• Hypertension
11. Spider Bites
• Black Widow bite treatment
– Mainly supportive
– Opiates
– Benzodiazepines
– Antivenom is available for severe cases
– IV calcium is ineffective
– Resolves in 24-48 hrs
12. Spider Bites
• Brown recluse- ½ inch in size
• Venom lyses cell walls
• Symptoms/Signs
– Initially painless
– Pain or itching around site
– Hemorrhagic blister to large ulcer
– Rare systemic symptoms
• Fever, chills, N/V, hemolysis, coagulopathy, DIC, shock
– Treatment
• Admit if systemic symptoms
• Hydration
• Local wound care
13. Burns
• 2nd
major cause of unintentional pediatric death
• Fires, scalds, flame, electrical, chemical
• 18% of burns are due to abuse
• Minor burns
– Infants with burns <10% BSA
– Children with burns <15% BSA
– No significant inhalation injury
• Major burns
– Infants with burns >10% BSA
– Children with burns >15% BSA
– Significant inhalation injury
14. Burn First Aid
• Extinguish flames
• ABCs
• Remove clothing
• Wash off chemicals
• No grease, butter or ointments
• Cover burn with clean dry sheet
– Cold, wet compresses to small burns
– Cold, wet dressing on large burns will lead to
hypothermia
15. Burn Classification
• First Degree
– Superficial redness, minor swelling, pain
– Resolves in ~ 1week
• Second Degree
– Blisters or Blebs, redness, pain
– Takes 1-3 weeks to heal
• Third Degree
– Dry, leathery, waxy, NO PAIN
– Requires skin grafting if large
16. Burn Surface Area
• Rule of nines (>14 yo)
– Head and Neck: 9%
– Each upper limb: 9%
– Thorax and abdomen front: 18%
– Thorax and abdomen back: 18%
– Perineum: 1%
– Each lower limb: 9%
• Rule of palm (<10 yo)
– Can use in small burns
– Child’s palm (not including fingers) = 1% BSA
– Or use an age appropriate burn chart
17. Minor Burn Care
• First degree requires no therapy
• Second degree
– Clean with soap and water daily
– Leave blisters intact, debride when ruptured
– Antibiotic ointment (Silvadene or bacitracin)
– Change dressing one time per day
– Facial burn may be left open
– Pain control
– Update tetanus
18. Major Burn Care
• ABCs
– Intubate early if going to require significant pain meds or if signs of
airway edema
– Consider carbon monoxide poisoning
• IVF for burns >15% of BSA
• Urine output is the best indicator of hydration status
– Maintain UOP 1ml/kg/hr
– Place foley catheter
• Parkland formula
– 4cc X wt (kg) X %BSA burned
– Give ½ the total volume in the first 8 hours and the other ½ volume in
the subsequent 16 hours
• Pain control
• Circumferential burns are at risk for compartment syndrome
19. Burns
• When to refer to a burn center
– Burns > 15% of BSA
– Larger burns of: hands, feet, face, perineum
– Concerns for abuse
20. Electrical Burns
• Minor electrical burns
– Most are asymptomatic
– Minor cleaning and antibiotic cream
– Electrical cord bites with burns to the oral
commissure require follow up with a burn
surgeon
21. Electrical Injuries
• High-tension, electrical wires or lightning
– Serious: Admit all patients
– Look for:
•Deep muscle injury
•Cardiac arrhythmias
•Seizures
•Fractures (from severe muscle tetany)
•Rhabdomyolysis and renal failure
– Electrical burns can show little surface area
damage with deep-tissue burns present
23. Acute Abdomen
• Findings
– Bilious vomiting
– Blood in stools
– Absent bowel sounds
– Abdominal distention/rigidity
– Rebound tenderness or involuntary guarding
– Localized tenderness
– Exquisite pain with movement or walking
24. Head Trauma
• Common pediatric complaint
• Most are not serious-require observation
only
• Symptoms
– Vomiting
– Lethargy
– Headache
– Irritability
– Behavioral changes
25. Basilar Skull Fracture
• Raccoon eyes: bruising under eyes
• Battle’s Sign: postauricular bruise
• Raccoon eyes and battle’s sign take hours
to develop
• Hemotympanum: blood behind tympanic
membrane
• CSF otorrhea
26. Temporal Bone Fracture
• Bleeding from external auditory canal
• Hemotympanum
• Hearing loss
• Facial paralysis
• CSF otorrhea
27. Head Injury
• Physical findings
– Papilledema does not develop immediately-
takes weeks to months and is a LATE sign of
intracranial hypertension
– Do a retinal exam in any patient with altered
consciousness, coma or seizures to evaluate
for retinal hemorrhage (Abuse!)
– Maintain a high index of suspicion for head
injury in adolescents with drug or alcohol use
28. Head Injury
• Physical findings
– Cushing’s triad (impending herniation)
•Bradycardia
•Hypertension
•Irregular respirations
– There does not have to be significant external
signs (i.e. bruising, hematoma) to have a
significant brain injury
29. Head Injury
• CT scan
– Best for identifying intracranial injury
– Can miss skull fractures
• Skull x-ray
– Best study to diagnose skull fractures
30. Who to Image?
• Mild head injury with no LOC
– Thorough history
– Normal exam
– Observe in office, ED or at home
• Mild head injury with brief LOC (<1min)
– Thorough history
– Normal exam
– CT scan or observe in office/ED
31. Who to Image?
• Order head CT if
– Penetrating trauma
– LOC > 1 min
– Altered level of consciousness
– Focal neurologic abnormalities
– Full fontanelle
– Seizure
– Amnesia for event
– Signs of basilar or temporal fxs
– Persistent vomiting
– Progressive headache
– Coagulopathy or bleeding disorder
32. Head Injury
• Treatment
– Airway / Breathing
•Control C-spine
•Intubate for GCS < 8
•Normal ventilation (maintain PCO2 30-35)
– Circulation
– Neurologic- mannitol or 3% saline for signs of
herniation
– Prompt CT for detection of surgical lesion
– Place OG tube- NG tubes are contraindicated!
33. Concussion
• Trauma-induced alteration in mental status with
or without loss of consciousness
– Confusion
– Loss of consciousness
– Disturbance of vision
– Loss of equilibrium
– Amnesia
– Headache or dizziness
– Lethargy
• Perform neuro exam
34. Concussion
• Player must be asymptomatic for 1 week
before returning to play
• Second-impact syndrome: head injury
before full recovery from a previous injury
can cause loss of autoregulation of
cerebral blood flow with rapid
development of increase intracranial
pressure
35. Colorado Medical Society Guidelines
Grading and 1st
Concussion guidelines
Grade Confusion Amnesia LOC Minimum
time to return
to play
Time
asymptomatic
I Yes No No 20 minutes When
examined
II Yes Yes No 1 week 1 week
III Yes Yes Yes 1 month 1 week
36. Colorado Medical Society Guidelines for Return to
Contact Sports after Repeated Concussions
Grade Minimum time to
return to play
Time asymptomatic
I (2nd
time) 2 weeks 1 week
II (2nd
time) 1 month 1 week
III (2nd
time)
I, II (3rd
time)
Season over 1 week
37. Orthopedics
• Must evaluate neurologic and vascular
status
– High risk fractures for neurovascular injury
•Supracondylar fractures
•Any significantly displaced/deformed fracture
38. Growth Plate Fractures
• Salter Harris Classification (SALTS)
– I Separated through the physis
– II Above (metaphysis)
– III Lower (epiphysis)
– IV Together (metaphysis + epiphysis)
– V Smashed (compressed growth plate)
39.
40. Growth Plate Fractures
• I and V difficult to see on radiographs
• II is most common
• III and IV require orthopedics
• If you suspect a fracture with a negative x-
ray, treat as a fracture and x-ray again
later
41. Greenstick Fracture
• Fractured cortex on the tension side and a
plastic deformity on the compression side
• Not a complete fracture through the bone
• Deformity occurs and needs to be reduced
42. Torus Fracture
• Compression of the bone produces a torus
(buckle) fracture
• An incomplete fracture (like greenstick fx)
• Most common in the distal metaphysis
• Heals well after 3 weeks of immobilization
43. Greenstick vs. Torus Fractures
• Greenstick
– Incomplete fracture
– Fracture of cortex on the
TENSION side
– Plastic deformity on
compression side
– Deformity occurs
– Can be unstable (deformity
in splint/cast can worsen)
– Reduction usually required
• Torus
– Incomplete fracture
– Fracture of cortex on the
COMPRESSION side
– Cortex on tension side
intact
– No deformity
– Stable
– No reduction if angulation
is insignificant
44. Spiral Fracture
• Fracture has a curvilinear course
• Common in toddlers
• Think abuse in children who are not
walking
45. Clavicle Fractures
• Most common fracture in childhood
• Usually middle and lateral portion of
clavicle
• Neurovascular injury uncommon
• Treatment
– Place arm in sling
– Heals in 3-6 weeks
– Rarely requires surgery
46. Distal Humerus Fractures
• Supracondylar: Most common elbow
fracture
• Fall on outstretched hand or elbow
• Posterior fat pad sign increases suspicion
• High risk of complication!!
– Displaced fractures can have brachial artery,
medial or radial nerve damage
47. Supracondylar Fractures
Classification
• Type I - nondisplaced
• Type II - displaced with intact posterior
cortex
• Type III - displaced with no cortical
contact
• Type III fractures increased risk of
neurovascular compromise &
compartment syndrome.
• Orthopedic consult
48. Fracture Complications
• Neurovascular compromise
• Compartment Syndrome
– Common with tibial fractures
– Fracture, swelling vascular injury lead to
ischemia
– Tissue blood flow compromised
– Pulses may be normal
– Pain out of proportion to fracture or remote to
the fracture site
49. Nursemaid’s Elbow
• Subluxation of the radial head
• 6mos to 5 yrs
• Mechanism: traction on a pronated wrist
• Annular ligament slides over radial head
• Affected arm with elbow slightly bend held
limply to child’s side
• Exam: No tenderness to palpation at elbow but
pain with elbow movement
• No x-ray necessary
50. Nursemaid’s Elbow
• Reduction:
– Flexion of elbow with supination of the
forearm OR hyperpronation of the forearm
– Return of function within 15 min
51. Shoulder Injuries
• Acromioclavicular separation
– Occurs in athletes (contact sports)
– The clavicle separates from the scapula
– Tenderness over the AC joint
– Sling and pain meds for minor separation
– Referral to ortho for more severe separations
52. Sprains
• Injury to the ligament around a joint
• **Rare in prepubescent children-the ligament is
stronger than the growth plate and will cause a
fracture rather than a sprain**
• Physical exam
– Tenderness
– Swelling
– Bruising
– Ligament laxity
53. Sprains
• Obtain x-ray to rule out fracture
• Treatment: RICE (rest, ice, compression
and elevation)
• Ice 20 min every 2 hours for 48 hours to
prevent swelling
• Severe sprain may require splint for
protection, comfort and stability
54. Eye Emergencies
• 1/3 of all blindness in children results
from trauma
• Boys 11-15 yrs are most vulnerable
• Injuries are caused by sports, sticks,
fireworks, paintballs and air-powered BB
guns
55. Eye Emergencies
• Corneal abrasions
– Pain, tearing, photophobia, decreased vision
– Dx by fluorescein dye and slit lamp/woods lamp
exam
– Abrasions are transparent, ulcers are opaque but both
light up under fluorescein
– Tx: Topical antibiotic ointment and recheck the next
day (do not send home on topical anesthetics, i.e.
tetracaine)
– Remember to check for corneal abrasion in an
irritable infant!
56. Eye Emergencies
• Penetrating globe injury
– Protect eye with styrofoam cup or rigid eye
shield
– Minimal manipulation
– May be missed because can seal over
– Do not put pressure on the globe
– May cause a distorted pupil or collapse of the
anterior chamber
– Think about this if there is broken glass
involved!!
57. Eye Emergencies
• Hyphema
– Blood in the anterior chamber
– Caused by blunt or perforating injury
– Bright or dark red fluid between the cornea
and iris
– Causes eye pain and somnolence
– Tx: bed rest, elevated head of bed 30-45
degrees, may use topical steroids and oral
amniocaproic acid
58. Eye Emergencies
• Chemical burns
– Alkali burns are the worst-they can penetrate
very deep into the eye
– Acids cause less severe, localized tissue
damage
– Both can cause corneal opacification
– Immediately treat with copious amounts or
saline irrigation (may need 5-6 LITERS)
– Use pH paper- want neutral pH
59. Eye Emergencies
• Lacerations of the eyelid
– Need optho to repair in the OR
– Lac to upper lid may involve the levator or
tarsal plate
– Lacs near medial canthus may involve the
nasolacrimal duct (requires microsurgical
repair)
– Examine the globe for penetrating injury
60. Eye Emergencies
• Blowout fracture
– Fracture of the walls or the floor of the orbit
– Occur with blunt trauma (balls, fist, etc)
– Dx by CT or plain x-ray (Waters view)
– Signs
•Limitation of upward gaze (causes diplopia)-
caused by entrapment of the inferior rectus muscle
•Nosebleed
•Orbital emphysema
•Hypesthesia of the ipsilateral cheek and upper lip
61. Toxicology
• Lots of Tox on the Boards!
• 2 million events/yr
• 60% are less than 6 yrs old
• Peak age: 18mo- 3yrs
• 92% occur at home
• 92% involve 1 substance
• 75% are managed at home
62. Who gets poisoned?
• 85% unintentional
– Toddlers
– Boys>girls
– Looks like candy
– Exploratory
– 60% are non-pharmaceutical ingestions
• 15% intentional
– Adolescents and adults
– Girls > boys
– Usually ingest pharmaceuticals
63. Poison Control Centers
• Good source for information-such as
signs/symptoms of toxicity, management,
etc.
• Can provide recommendations for home
care
• Can calculate dosage toxicities
• Identification of ingested substances
64. Poison Management
• Prevention!!
– Discuss storage of poisonous substances at the 6 mo
visit!!
• ABCDs and stabilize
• Identify the toxin
• Prevent further absorption of toxin
• Enhance elimination of toxin
• Antagonists and antidotes
• Decontaminate-remove clothing
65. Poison Management
• What?
– Home search, bring the container
• When?
– Useful in interpreting drug levels
• How?
– Route and site of exposure
– Intentional vs. unintentional
• How much?
– “Worst case scenario”
– Average swallow of young child: 5-10 cc, of older
child or adolescent: 10-15 cc
66. Poison Management
• Exam
– ABCs
– HR, RR, Blood pressure
– Neuro status
– Pupillary exam (key to some toxidromes)
– Breath odor
– Skin: temp, color, diaphoresis
68. Poison Management
• Prevention of absorption
– Dermal: remove clothing, wash skin (15 min)
– Ocular: irrigate eyes with normal saline
– Respiratory: remove pt to fresh air
– Prevent GI absorption
•Activated charcoal
•Gastric lavage
•Cathartics
•Whole bowel irrigation
69. GI Decontamination
• Most liquids absorbed in 30 min
• Most solids absorbed in 1-2 hrs
• Contraindication to GI decontamination
– Coma or altered mental status (no airway
protection)
– Hematemesis
– Seizures
– Hydrocarbon ingestion
– Acids, alkalis and sharp objects
71. GI Decontamination
• Activated charcoal
– Most commonly used method
– Adsorbs the ingested substance
– Dose = 1gram/kg
– Most benefit if given within 1 hr of ingestion
72. GI Decontamination
• Activated charcoal
– Complications
•Pulmonary aspiration
•Emesis
•Constipation or intestinal obstruction
– Contraindications
•Hydrocarbons or corrosives
•Ileus
•Compromised airway/ altered mental status
73. GI Decontamination
• Activated charcoal ineffective=
CHEMICaL CamP
– C cyanide C camphor
– H hydrocarbon P phosphorus
– E ethanol
– M metals
– I iron
– C caustics
– L lithium
74. GI Decontamination
• Gastric lavage
– Not routine
– Consider if life-threatening ingestion within
30-60 min
– Absence of pill fragments does not rule out
toxic ingestion
– Requires large bore tube, lavage until clear
75. GI Decontamination
• Gastric lavage
– Complications
•Aspiration
•Laryngospasm
•Mechanical injury to throat/esophagus/stomach
•Fluid and electrolyte imbalance
– Contraindications
•Hydrocarbon, acid, alkali ingestion
•Compromised airway/ altered mental status
•Patients with GI pathology (ulcers, recent surgery)
76. GI Decontamination
• Cathartics
– Limited use, only 1 dose recommended if
used
– Sorbitol is most commonly used agent
– Never used alone-mixed with charcoal
– Side effects: Nausea, abd cramps, vomiting,
transient hypotension
– Can cause dehydration, hypernatremia if
multiple doses given
77. GI Decontamination
• Whole bowel irrigation
– Cleanses the whole bowel
– Uses polyethylene glycol electrolyte solution
– Useful for iron, concretions (aspirin), drug-
filled packets, sustained release drugs
– Potential to reduce drug absorption by
decontamination or the whole GI tract
79. Tox Mnemonics
• Miosis (small pupils) = COPS
– C cholinergics, clonidine
– O opiates, organophosphates
– P phenothiazine, pilocarpine, physostigmine
– S sedatives (barbituates)
80. Tox Mnemonics
• Mydriasis (dilated pupils) = AAAS
– A antihistamine
– A antidepressant
– A anticholinergic, atropine
– S sympathomemetics (amphetamine,
cocaine, PCP)
81. Tox Mnemonics
• Diaphoretic skin = SOAP
– S sympathomimetics
– O organophosphates
– A asa (salicylates)
– P phencyclidine (PCP
• Red skin= carbon monoxide, boric acid
• Blue skin=cyanosis, methemoglobinemia
82. Tox Mnemonics
• S salivation
• L lacrimation
• U urination
• D diarrhea
• G GI distress
• E emesis
• D diarrhea, defecation
• U urination
• M miosis, muscle
• B bradycardia
• B bronchospasm,
bronchorrhea
• E emesis
• L lacrimation
• S sweating, salivation
Organophosphates= SLUDGE or DUMBBELS
83. Tox Mnemonics
• Compounds visible on abd x-ray=CHIPES
– C chloral hydrate, calcium, cocaine condoms
– H heavy metals, halogenated hydrocarbons
– I iron, iodine
– P phenothiazine, potassium, pepto-bismol
– E enteric coated tabs
– S salicylates, sustained-release tabs
84. Tox Mnemonics
• Increased anion gap= MUDPILES
– M methanol
– U uremia
– D DKA
– P phenols, paraldehyde
– I iron, isoniazid, inhalants, ibuprofen,
inborn errors
– L lactate (CO, cyanide)
– E ethanol, ethylene glycol
– S salicylates, solvents (benzene, toluene)
85. Tox Mnemonics
• Increased osmolar gap= MAD GAS
– M mannitol
– A alcohols and glycols
– D diatrizoate (iodine contrast agent)
– G glycerol
– A acetone
– S sorbitol
86. Tox Mnemonics
• Hypoglycemia = HOBIES
– H hypoglycemia
– O oral hypoglycemics
– B beta blockers
– I insulin
– E ethanol
– S salicylates
87. Pharmaceutical Ingestions
• Content specifications for specific substances
– Acetaminophen Salicylates
– Anticholinergics Theophylline
– Clonidine Tricyclic Antidepressants
– Ibuprofen
– Iron
– Opiates
– Phenothiazines
88. Acetaminophen
• Rapidly absorbed
• Metabolized in liver using glutathione
• In toxicity, glutathione stores
overwhelmed and toxic metabolite
accumulates
• Commonly combined with other drugs
(lortab, roxicet, etc)
89. Acetaminophen
• Acute toxic dose
– Minimum toxic dose 150mg/kg
– Healthy children 1-6 yo: 200mg/kg
– Adolescents and adults: 7.5 grams
• Chronic toxic dose
– Repeated large doses may lead to toxicity
– More subacute course
90. Acetaminophen
• Overdose symptoms
– 0-24hrs: GI irritation
• Nausea, vomiting, normal LFTs
– 24-48hrs: Latent period
• Asymptomatic
• RUQ pain develops
• LFTs increase
– 48-96hrs: Hepatic failure
• Peak symptoms
• AST> 2000, prolonged PT, elevated bilirubin
• Coagulopathy
– 4-14days: Recovery or death
• Death from hepatic failure
• Symptoms resolve in survivors
91. Acetaminophen
• Management
– Prevent absorption: activated charcoal
– Acetaminophen levels
•Peak concentration at 4 hrs post ingestion
•Remember patient is asymptomatic when damage
is occurring!
•Rumack-Matthew nomogram
– Used for single acute poisoning
– Can not be used if time of ingestion is unknown or if
repeated supratherapeutic ingestion
93. Acetaminophen
• Overdose treatment
– N-acetylcysteine (NAC)- IV form
– Acetylcysteine (Mucomyst)- oral form
– Give for toxic levels
– Must give full course if started
– IV is as effective as PO
– Regenerates glutathione stores to be able to
metabolize the acetaminophen to a nontoxic
metabolite
95. Anticholinergics
• Hot as a hare: hyperthermia, tachycardia
• Blind as a bat: mydriasis (blurred vision)
• Red as a beet: flushed skin
• Dry as a bone: decreased sweat, urine,
dry mucous membranes
• Mad as a hatter: delirium, seizures,
agitation
• Bloated as a bladder: urinary retention
96. Anticholinergics
• Treatment
– Activated charcoal if good mental status
– Supportive care
– Physostigmine
•Reversibly inhibits cholinesterases and allows
ACH to accumulate
•Use is controversial
97. Clonidine
• Antihypertensive with alpha-2-adrenergic
receptor stimulation
• Children are very sensitive (0.1mg is toxic)
• Rapid onset (1hr)
• Gastric decontamination not helpful
• Get ECG and blood gas
• Supportive care
• Resolves within 24 hrs of ingestion
99. Ibuprofen
• Serious side effects are rare
• <100 mg/kg does not cause toxicity
• >400 mg/kg can cause serious toxicity
• Symptoms within 4 hrs and resolve within
24 hrs
– Nausea, vomiting, epigastric pain,
drowsiness, lethargy, ataxia
100. Ibuprofen
• Causes anion gap metabolic acidosis
• Renal failure
• Coma or seizures (rare)
• Treatment
– Activated charcoal
– Supportive care
– Monitor renal function and acid/base status
101. Iron
• Serious toxicity
• Prenatal vitamins, iron supplements
• Pathophysiology
– Corrosive to gastric/intestinal mucosa
(strictures)
– Mitochondrial and cell dysfunction
– Capillary leak leads to hypotension
• Toxic dose
– 60mg/kg of elemental iron
102. Phases of Iron Toxicity
• Phase 1: GI stage (30min-6hrs)
– N/V, diarrhea, abd pain, hematemesis
– Direct damage to GI/intestinal mucosa
• Phase 2: Stability (6-12hrs)
• Phase 3: Systemic toxicity (within 48hrs)
– Cardiovascular collapse
– Severe metabolic acidosis (high anion gap)
• Phase 4: Hepatic toxicity (2-3 days)
– Hepatic failure
• Phase 5: GI scarring (2-6 weeks)
• IRON= Indigestion, Recovery, Oh my Gosh (stage 3,4),
Narrowing
103. Iron
• Diagnosis
– X-ray may confirm ingestion
•Liquid preps and chewables not visible
– Obtain serum iron levels
•4 hrs after ingestion
•<300mcg/dL: minimal toxicity
•>500mcg/dL: severe toxicity
104. Iron
• Treatment
– Supportive and symptomatic care
– Chelation with IV deferoxamine
•Binds free iron in serum
•Treat if iron level 350-500 +symptoms
•Treat all iron level >500
•Treat if ingested dose >60mg/kg
•Patients will develop “vin rose” urine
•Does not treat corrosive effects of iron in the GI
tract
105. Iron
• Therapy adjuvants
– Whole bowel irrigation
– Endoscopic gastric pill removal
– Do NOT use ipecac, gastric lavage
– Activated charcoal does NOT bind iron
106. Opiates
• Most cases present from drug abuse
• Acts on receptors in the brain
• Ex: Morphine, heroin, methadone,
codeine, meperidine
107. Opiates
• Symptoms
– Drowsiness
– Coma
– Change in mood
– Analgesia
– N/V
– Respiratory
depression
– Abdominal pain
• Physical Findings
– Miosis
– Respiratory
depression
– Coma
– Decreased GI motility
– Hypotension
– Bradycardia
– Hypothermia
– Hyporeflexia
Respiratory and CNS depression with pinpoint pupils = Opiate overdose
108. Opiates
• Treatment
– ABCs
– Intubation
– Naloxone (Narcan) is the antidote
• use if respiratory depression
• Can be give Sub-cutaneously or IV
• Dose: 0.1-0.4mg/kg
• Short acting-may need to redose if opioid is long-acting
• Can precipitate opioid withdraw in chronic opiate users
110. Phenothiazines
• Treatment
– ABCs
– Vasoactive drugs for hypotension
– Diphenhydramine for dystonic reactions
– Can use charcoal if not contraindicated
***Remember Phenothiazines and clonidine can
cause transient HYPERtension***
119. The ECG in TCA Overdose
• Sinus tachycardia
• Right Axis Deviation of the Terminal 40 msec
– R wave in AvR
– S wave in I
• QT prolongation
• Prolonged QRS: blockage of fast Na+ channels
slows depolarization of action potential and
delays ventricular depolarization
– >100 msec: risk for seizures
– >160 msec: risk for arrhythmias
120. Tricyclic Antidepressants
• Treatment
– ABCs
– Charcoal
– Continuous ECG monitoring
– IV sodium bicarb drip-want pH 7.45-7.55 to prevent
dysrhythmias
– Do not use physostigmine
– Treat seizures with benzos or phenobarb, do not use
phenytoin
– Monitor potassium closely
124. Carbon Monoxide
• Labs
– Obtain CO concentration (carboxyhemoglobin)
– >15-20% CO symptomatic
– Pulse ox may be NORMAL
• Treatment
– Oxygen-give by high-flow non-rebreather face mask
– Cardiac monitoring
– Correct anemia
– Hyperbaric chamber therapy is controversial
– Consider cyanide poison if from a house fire
125. Caustic Ingestions
• Acidic agents
– Toilet bowel cleaners, rust remover, metal cleaners
– Bitter
– Superficial coagulation necrosis
– Thick eschar formation
– Severe gastritis
• Alkali agents
– Oven and drain cleaners, hair relaxer, automatic
dishwasher detergent
– Tasteless
– Severe, deep liquefaction necrosis
– Household bleach (5%) is only an irritant
126. Caustic Ingestions
• Signs and symptoms
– Drooling
– Refusal to drink
– Vomiting
– Oral burns
– Dysphagia
– Stridor or resp distress
– Chest or abdominal pain
127. Caustic Ingestions
• Work-up
– No symptoms usually means little or no injury
– Patients with esophageal burns:
• 60-80% have burns to the mouth
• 20-45% have NO burns to the mouth
**Absence or oral lesions does not preclude severe
esophageal or stomach injury**
– Upper endoscopy (12 hrs after ingestion) for all
patients with oral burns or symptoms
– CXR
128. Caustic Ingestions
• Treatment
– Remove contaminated clothing
– Observe for complications
– NO gastric lavage or activated charcoal
– Endoscopy within 24-48 hrs-evaluate for
burns, perforation, severe gastritis
**May have late stricture formation**
130. Caustic Ingestions
• Hydrochloric or sulfuric acids can cause:
– Severe gastritis
– Perforation
– Peritonitis
– Late strictures
– All of these can happen without evidence of
oral or esophageal burns!!
132. Hydrocarbon Ingestion
• Clinical findings
– Coughing, choking, gagging
– Tachypnea, wheezing, resp distress
– Mild CNS depression
– Fever
• Labs
– Leukocytosis
– CXR (may be normal for up to 24 hrs after
exposure)
133. Hydrocarbon Ingestion
• Treatment
– Dermal decontamination
– Observe for 6 hrs and discharge if:
• Patient presented without symptoms
• Remains asymptomatic
• No findings on CXR
• Normal O2 sats
– If symptomatic at any time or if positive x-ray admit
for:
• Supportive care
• Airway control
• ARDS treatment
140. Methanol
• Treatment
– Activated charcoal NOT effective
– Sodium bicarb for acidosis
– Hemodialysis (also corrects acidosis)
– Antidotes:
• IV ethanol
• Fomepizole (inhibits alcohol dehydrogenase and prevents
the metabolism of methanol to toxic metabolite)
• Folic acid/ leucovorin (helps convert formic acid into CO2
and H2O)
143. Ethylene Glycol
• Labs
– Ethylene glycol level
– Elevated osmolar gap
– Elevated anion gap (anion gap acidosis)
– Urine fluoresces under woods lamp
– BMP-monitor BUN/ Cr., calcium (oxalate binds ca)
– Falsely elevated lactate (analyzers interpret glycolic
acid as lactic acid)
– UA-look for calcium oxalate crystals
144. Ethylene Glycol
• Treatment
– Activated charcoal NOT effective
– Sodium bicarb for acidosis
– Calcium for symptomatic hypocalcemia
– Hemodialysis (also corrects acidosis)
– Antidotes:
•IV ethanol
•Fomepizole (inhibits alcohol dehydrogenase and
prevents the metabolism of methanol to toxic
metabolite)
145. Organophosphates
• Pesticides: diazinon, malathion
• Binds to cholinesterase leading to excess
acetylcholine (can’t break down ACH)
• Bond becomes permanent in 2-3 days
• Takes weeks to months to regenerate
enzyme
147. Organophosphates
• Treatment
– Provider must wear protective clothing
– ABCs
– Decontaminate, wash skin with soap/water
– Benzos for CNS symptoms
– Antidotes:
• Atropine for increased secretions, bradycardia
• Pralidoxime (2-PAM)
– Reactivates acetylcholinesterase activity
– only effective before bond becomes permanent
– Use with atropine
148. Plants
• Contact poison control as your resource
• GI upset most common symptom
• Dieffenbachia and philodendron are
house plants that cause oral pain
• Poinsettia, mistletoe and holly cause GI
symptoms
149. Plants
• Foxglove, oleander and lily of the valley
have digitalis-like toxicity
• Jimson weed, deadly nightshade cause
anticholinergic poisoning
• Lethal mushrooms have delayed
symptoms (liver toxicity)
150. Esophageal Foreign Bodies
• Children 6mo -3 yrs
• Coins the most common
• Get stuck at:
– Upper esophageal sphincter (cricopharyngeal
muscle)
– Aortic arch
– Lower esophageal sphincter (gastroesphageal
junction)
152. Esophageal Foreign Bodies
• Diagnosis
– Radiograph
•Coin flat on AP (get lateral to look for multiple
coins)
•Coin on edge on AP if in trachea
– Radiolucent objects
•Endoscopy
•Contrast esophagram
– Metal detector
153. Esophageal Foreign Bodies
• Treatment
– Observe for 24 hours if:
•No symptoms
•<24 hrs old
•Blunt object
– Endoscopic removal
•Gold standard
•Urgent for respiratory symptoms
– Foley catheter extraction under fluoroscopy
– Push object into stomach using a bougienage
154. Esophageal Foreign Bodies
• Disc/ Button Batteries
– Liquefaction necrosis and perforation can occur if disc
battery is lodged in esophagus
– Batteries in esophagus should be removed
IMMEDIATELY (mucosal injury w/in 1 hr, full
thickness injury w/in 4 hrs)
– If the disc battery is in the stomach:
• Most pass without consequence- monitor stools
• Do not need to be retrieved unless remains in the stomach
>48 hrs or is a large diameter battery (>20mm)
155. Lacerations/Wounds
• Laceration Tips
– Irrigation is the best method of cleansing
– Update tetanus
– No topical skin adhesives in scalp or bites
– No LET gel on fingers, nose, toes, penis
– Eyelid lacs require an ophthalmologist for
repair
156. Lacerations/Wounds
• Wound management
– Hemostasis
– History of wound mechanism
– Tetanus immunization history
– Thorough wound cleaning
– Remove debris
– Debride devitalized tissue
– Closure of wound
157. Lacerations/Wounds
• Lip lacs
– Lac through vermillion border requires exact
approximation of the wound margins
– Must take into consideration swelling of the
soft tissue of the lips
158. Lacerations/Wounds
• Wound cleaning
– Irrigation with mild pressure
– Remove dirt or foreign bodies
– Iodine use is controversial
– Debride necrotic tissue
– Do NOT shave hair or eyebrows
160. Lacerations/Wounds
• Puncture wounds
– Primary closure is not necessary
– Obtain x-rays to look for foreign body
– Prophylactic antibiotics usually not indicated
– Complications
•Secondary infection (6-10%)
•Retained foreign body
•Osteochondritis (esp with puncture wounds of
hands or feet)
161. Puncture Wounds
• Common causes of infection
– Staphylococcus
– Streptococcus
– Pseudomonas (esp if puncture wound
through a sneaker)
162. Lacerations/Wounds
• Tetanus
– Children with 3 or more immunizations:
•Clean, minor wound: no tetanus if last dose w/in
10yrs
•All other wounds: give tetanus if more than 5 yrs
since last dose
– If tetanus status unknown or less than 3 doses
•Clean, minor wound: give TD
•All other wounds: give TD and tetanus immune
globulin
163. Pathologist on Trial
During a murder trail, a pathologist was cross-examined by a
defense attorney.
Attorney: Did you take a pulse before you gave the death
certificate?
Pathologist: No.
Attorney: Did you listen to the heart?
Pathologist: No.
Attorney: Did you check for breathing?
Pathologist: No.
Attorney: This means that you were not sure that the patient was
dead when you signed the death certificate?
Pathologist: Let me put it this way. The man’s brain was in a jar on
my desk. But I guess it’s possible he could be out there practicing
law somewhere.
