Emergency medicine board review

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Emergency medicine board review

  1. 1. Emergency Medicine Board Review Tricia Falgiani, MD
  2. 2. EM Specific Subjects • Anaphylaxis • Resuscitation • Environmental (bites, burns, drowning) • Acute Abdomen • Head Trauma • Orthopedics (fractures, dislocations) • Ophthalmology • Toxicology • Lacerations
  3. 3. Anaphylaxis • IgE mediated • Clinical Findings – Skin-puritis, urticaria, flushing, angioedema ***Skin findings may be absent in up to 20% – Respiratory-sneezing, cough, wheezing, dyspnea – Cardiovascular-hypotension, dysrhythmias, myocardial ischemia – GI-nausea, vomiting, abdominal cramps, diarrhea
  4. 4. Anaphylaxis • Treatment – IntraMUSCULAR epinephrine – Corticosteroids – H1 antihistamine antagonist (Zyrtec, Benadryl) – H2 antihistamine antagonist (Zantac, Tagamet) – Nebulized albuterol – IV fluids and oxygen • Prevention – Allergen Avoidance – Read food labels – Epi-pen – Written emergency action plan for accidental ingestion
  5. 5. Resuscitation • Know PALS – ABCs – Bradycardia algorithm – Tachycardia algorithm – Pulseless arrest algorithm •V-fib/V-tach •Asystole/ PEA
  6. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 19. Burns • When to refer to a burn center – Burns > 15% of BSA – Larger burns of: hands, feet, face, perineum – Concerns for abuse
  20. 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. 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
  22. 22. Acute Abdomen • Intussusception • Congenital abnormalities • Malrotation with volvulus • Appendicitis • GI perforation • Trauma • Testicular/ovarian torsion
  23. 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. 24. Head Trauma • Common pediatric complaint • Most are not serious-require observation only • Symptoms – Vomiting – Lethargy – Headache – Irritability – Behavioral changes
  25. 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. 26. Temporal Bone Fracture • Bleeding from external auditory canal • Hemotympanum • Hearing loss • Facial paralysis • CSF otorrhea
  27. 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. 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. 29. Head Injury • CT scan – Best for identifying intracranial injury – Can miss skull fractures • Skull x-ray – Best study to diagnose skull fractures
  30. 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. 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. 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. 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. 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. 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. 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. 37. Orthopedics • Must evaluate neurologic and vascular status – High risk fractures for neurovascular injury •Supracondylar fractures •Any significantly displaced/deformed fracture
  38. 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. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. Spiral Fracture • Fracture has a curvilinear course • Common in toddlers • Think abuse in children who are not walking
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. Nursemaid’s Elbow • Reduction: – Flexion of elbow with supination of the forearm OR hyperpronation of the forearm – Return of function within 15 min
  50. 50. 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
  51. 51. 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
  52. 52. 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
  53. 53. 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
  54. 54. 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!
  55. 55. 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!!
  56. 56. 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
  57. 57. 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
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. 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
  62. 62. 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
  63. 63. 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
  64. 64. 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
  65. 65. Poison Management • Exam – ABCs – HR, RR, Blood pressure – Neuro status – Pupillary exam (key to some toxidromes) – Breath odor – Skin: temp, color, diaphoresis
  66. 66. Poison Management • Labs – CBC, LFTs – Accucheck – Measured (not calculated) serum osmolality – Anion gap – ECG – Arterial ABG (determine acid-base status) – Drug levels (aspirin, acetaminophen, alcohols) – Abdominal x-ray
  67. 67. 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
  68. 68. 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
  69. 69. GI Decontamination • Ipecac – NOT recommended by the AAP!! – No home use
  70. 70. GI Decontamination • Activated charcoal – Most commonly used method – Adsorbs the ingested substance – Dose = 1gram/kg – Most benefit if given within 1 hr of ingestion
  71. 71. GI Decontamination • Activated charcoal – Complications •Pulmonary aspiration •Emesis •Constipation or intestinal obstruction – Contraindications •Hydrocarbons or corrosives •Ileus •Compromised airway/ altered mental status
  72. 72. 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
  73. 73. 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
  74. 74. 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)
  75. 75. 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
  76. 76. 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
  77. 77. GI Decontamination • Whole bowel irrigation – Contraindications •Bowel perforation •Bowel obstruction •Ileus •Compromised airway/ altered mental status •Hemodynamic instability •Intractable vomiting
  78. 78. Tox Mnemonics • Miosis (small pupils) = COPS – C cholinergics, clonidine – O opiates, organophosphates – P phenothiazine, pilocarpine, physostigmine – S sedatives (barbituates)
  79. 79. Tox Mnemonics • Mydriasis (dilated pupils) = AAAS – A antihistamine – A antidepressant – A anticholinergic, atropine – S sympathomemetics (amphetamine, cocaine, PCP)
  80. 80. 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
  81. 81. 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
  82. 82. 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
  83. 83. 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)
  84. 84. Tox Mnemonics • Increased osmolar gap= MAD GAS – M mannitol – A alcohols and glycols – D diatrizoate (iodine contrast agent) – G glycerol – A acetone – S sorbitol
  85. 85. Tox Mnemonics • Hypoglycemia = HOBIES – H hypoglycemia – O oral hypoglycemics – B beta blockers – I insulin – E ethanol – S salicylates
  86. 86. Pharmaceutical Ingestions • Content specifications for specific substances – Acetaminophen Salicylates – Anticholinergics Theophylline – Clonidine Tricyclic Antidepressants – Ibuprofen – Iron – Opiates – Phenothiazines
  87. 87. 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)
  88. 88. 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
  89. 89. 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
  90. 90. 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
  91. 91. Acetaminophen • Rumack-Matthew nomogram
  92. 92. 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
  93. 93. Anticholinergics • Blocks acetylcholine (ACH) at muscarinic receptors • Examples – Atropine Belladona – Antihistamines Muscle relaxants – Phenothiazines Mushrooms – TCAs Jimson weed
  94. 94. 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
  95. 95. Anticholinergics • Treatment – Activated charcoal if good mental status – Supportive care – Physostigmine •Reversibly inhibits cholinesterases and allows ACH to accumulate •Use is controversial
  96. 96. 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
  97. 97. Clonidine • Signs/ Symptoms – Lethargy – Miosis (remember COPS) – Bradycardia – Apnea – Coma – Hypotension – ***May cause transient HYPERtension****
  98. 98. 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
  99. 99. Ibuprofen • Causes anion gap metabolic acidosis • Renal failure • Coma or seizures (rare) • Treatment – Activated charcoal – Supportive care – Monitor renal function and acid/base status
  100. 100. 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
  101. 101. 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
  102. 102. 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
  103. 103. 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
  104. 104. Iron • Therapy adjuvants – Whole bowel irrigation – Endoscopic gastric pill removal – Do NOT use ipecac, gastric lavage – Activated charcoal does NOT bind iron
  105. 105. Opiates • Most cases present from drug abuse • Acts on receptors in the brain • Ex: Morphine, heroin, methadone, codeine, meperidine
  106. 106. 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
  107. 107. 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
  108. 108. Phenothiazines • Promethazine, prochlorperazine, chlorpromazine (antipsychotics) • Symptoms – Anticholinergic symptoms – CNS depression – Hypotension – **Transient HYPERtension** – Cogwheel rigidity – Dystonic reaction: neck spasms, tongue protrusion, oculogyric crisis
  109. 109. 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***
  110. 110. Salicylates • Aspirin, oil of wintergreen, antidiarrheal products • Pathophys: uncouples oxidative phosphorylation • Acute toxic dose: 150mg/kg
  111. 111. Salicylates • Signs and Symptoms – N/V – Tinnitus – Hyperventilation, respiratory alkalosis – Increased respiratory depth – Dehydration – Hypokalemia – Metabolic acidosis – Renal failure • Serious toxicity: hyperthermia, agitation, confusion, coma • Death occurs from pulmonary or cerebral edema, electrolyte imbalance, cardiovascular collapse
  112. 112. Salicylates • Diagnosis – Levels >30 mg/dL potentially toxic – Levels > 40mg/dL symptomatic – Levels >100mg/dL serious toxicity – Serially monitor levels – Labs: ABG, electrolytes, coags
  113. 113. Salicylates • Treatment – Activated charcoal-drug may form bezoar/concretions-may need multiple doses of charcoal – Aggressive fluid rehydration – Replace bicarbonate and potassium – Raise urine pH-enhances excretion – Hemodialysis
  114. 114. Theophylline • Narrow therapeutic window – Therapeutic level 10-20mcg/dL – >20 mcg/dL toxic • Signs/Symptoms – N/V Hypercalcemia – Mental status changes Hypokalemia – Seizures Metabolic acidosis – Hypotension – Tachyarrhythmias
  115. 115. Theophylline • Treatment – Repeated doses of activated charcoal – ABCs – Cardiac monitoring – Treat arrhythmias with beta blockers – Treat hypotension with fluids and pressors – Benzos for seizures – Monitor theophylline levels – BMP – Hemodialysis
  116. 116. Tricyclic Antidepressants • Usually prescribed to adolescents • Danger of accidental ingestion by siblings • Onset of symptoms within 2 hrs • Major complications occur within 6 hrs • Labs: – BMP (hypokalemia) – ABG (acidosis) – ECG – Urine tox screen: Look for co-ingestions!!
  117. 117. Tricyclic Antidepressants • Signs/Symptoms – Acidosis – Anticholinergic symptoms (dry, flushed skin, mydriasis, decreased bowel sounds, hyperthermia) – CNS effects • Lethargy • Agitation • Seizures • Coma – Cardiovascular effects • Tachycardia • Hyper or Hypo-tension • Widened QRS • Prolonged QT **Cardiac dysrhythmias occur LATE**
  118. 118. 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
  119. 119. 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
  120. 120. Environmental Ingestions • Content specifications for specific substances – Carbon monoxide Plants – Acids/Alkali Esophageal FB – Hydrocarbons – Ethanol – Methanol – Ethylene glycol – Organophosphates
  121. 121. Carbon Monoxide • Pathophysiology – Reversibly binds to hemoglobin and displaces oxygen – Impairs oxygen release (shifts curve to the left) – Impedes oxygen utilization – Colorless – Odorless – May cause cherry red skin
  122. 122. Carbon Monoxide • Symptoms – Headache – Dizziness – Nausea, vomiting – Visual changes – Weakness – Syncope – Ataxia – Seizures, coma death
  123. 123. 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
  124. 124. 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
  125. 125. Caustic Ingestions • Signs and symptoms – Drooling – Refusal to drink – Vomiting – Oral burns – Dysphagia – Stridor or resp distress – Chest or abdominal pain
  126. 126. 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
  127. 127. 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**
  128. 128. Caustic Ingestions • Complications – Necrosis – Esophagitis – Perforation – Stricture formation
  129. 129. 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!!
  130. 130. Hydrocarbon Ingestion • Mineral spirits, kerosene, gasoline, lamp oil • Low viscosity leads to pulmonary aspiration • Carbon tetrachloride causes liver toxicity • Inhaled propellants, refrigerants, toluene sensitize to cardiac arrhythmias
  131. 131. 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)
  132. 132. 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
  133. 133. Hydrocarbon Ingestion • DO NOT: – Use ipecac – Gastric lavage – Activated charcoal – Steroids – Prophylactic antibiotics – Epinephrine
  134. 134. Ethanol • Found in multiple products in the home: mouthwash, perfume • Signs/ Symptoms – CNS depression – N/V – Slurred speech – Ataxia – Stupor – Seizures, coma – Hypothermia – Hypoglycemia (inhibits hepatic gluconeogenesis)
  135. 135. Ethanol • Labs – Ethanol level – Elevated osmolar gap – Elevated anion gap (anion gap acidosis) • Treatment – ABCs – IV fluids – Treat hypoglycemia and hypokalemia – No activated charcoal – Hemodialysis rarely used • Ethanol intoxication may mask toxicities from co- ingestions.
  136. 136. Methanol • Windshield washer fluid, de-icing agents, solvents, canned heat (sterno), liquid fuels • Peak methanol levels in 1 hr • 80-90% hepatic metabolism • Methanol itself is harmless – It’s metabolite, FORMIC ACID, is extremely toxic
  137. 137. Methanol • Signs/ Symptoms – Initially: N/V, abdominal discomfort – 24hrs later: •Visual disturbance: blurry vision, photophobia, snowstorm •Optic nerve damage leads to blindness •CNS depression, coma, seizures •Severe metabolic acidosis
  138. 138. Methanol • Labs – Methanol level – Elevated osmolar gap – Elevated anion gap (anion gap acidosis)
  139. 139. 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)
  140. 140. Ethylene Glycol • Radiator fluid, antifreeze, coolants, inks, adhesives, glass cleaners • Peak level 1-4 hrs • 80% hepatic metabolism • Again it’s metabolites are toxic: – Glycolic acid – Oxalic acid (forms calcium oxalate crystals)
  141. 141. Ethylene Glycol • Signs/ Symptoms – Stage 1 (1-12 hrs): Intoxication • N/V, drowsiness, slurred speech, lethargy – Stage 2 (12-36 hrs) • Tachypnea • Cyanosis • ARDS or pulmonary edema • Coma, seizures • Metabolic acidosis – Stage 3 (2-3 days) • Cardiac failure, renal failure • Cerebral edema • DEATH
  142. 142. 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
  143. 143. 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)
  144. 144. 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
  145. 145. Organophosphates • Symptoms: SLUDGE & DUMBELS • Nicotinic symptoms – Muscle twitching, weakness, tremors – Respiratory weakness – Confusion – Coma – Slurred speech – Seizures – Altered mental status
  146. 146. 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
  147. 147. 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
  148. 148. 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)
  149. 149. 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)
  150. 150. Esophageal Foreign Bodies • Signs/ Symptoms – 30% asymptomatic (take all seriously) – Drooling – Dysphagia – Choking, gagging, vomiting – Cough, stridor, wheezing, dyspnea – Pain in neck, throat, chest
  151. 151. 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
  152. 152. 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
  153. 153. 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)
  154. 154. 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
  155. 155. Lacerations/Wounds • Wound management – Hemostasis – History of wound mechanism – Tetanus immunization history – Thorough wound cleaning – Remove debris – Debride devitalized tissue – Closure of wound
  156. 156. 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
  157. 157. 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
  158. 158. Lacerations/Wounds • Laceration complications – Tendon laceration – Arterial damage – Infection – Limited movement due to scar formation – Scarring – Keloid formation
  159. 159. 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)
  160. 160. Puncture Wounds • Common causes of infection – Staphylococcus – Streptococcus – Pseudomonas (esp if puncture wound through a sneaker)
  161. 161. 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
  162. 162. 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.

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