emergency medicine board review
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TRANSCRIPT
Emergency Medicine Board Review
Tricia Falgiani, MD
EM Specific Subjects
• Anaphylaxis• Resuscitation• Environmental (bites, burns, drowning)• Acute Abdomen• Head Trauma • Orthopedics (fractures, dislocations)• Ophthalmology• Toxicology• Lacerations
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
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
Resuscitation
• Know PALS– ABCs– Bradycardia algorithm– Tachycardia algorithm– Pulseless arrest algorithm
• V-fib/V-tach• Asystole/ PEA
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)
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
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
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)
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
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
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
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
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
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
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
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
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
Burns
• When to refer to a burn center– Burns > 15% of BSA– Larger burns of: hands, feet, face,
perineum– Concerns for abuse
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
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
Acute Abdomen
• Intussusception• Congenital abnormalities• Malrotation with volvulus• Appendicitis• GI perforation• Trauma• Testicular/ovarian torsion
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
Head Trauma
• Common pediatric complaint• Most are not serious-require
observation only• Symptoms
– Vomiting– Lethargy– Headache– Irritability– Behavioral changes
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
Temporal Bone Fracture
• Bleeding from external auditory canal
• Hemotympanum• Hearing loss• Facial paralysis• CSF otorrhea
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
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
Head Injury
• CT scan– Best for identifying intracranial injury– Can miss skull fractures
• Skull x-ray– Best study to diagnose skull fractures
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
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
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!
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
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
Colorado Medical Society Guidelines
Grading and 1st Concussion guidelinesGrade 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
Colorado Medical Society Guidelines for Return to Contact Sports after Repeated
ConcussionsGrade Minimum time to
return to playTime 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
Orthopedics
• Must evaluate neurologic and vascular status– High risk fractures for neurovascular
injury• Supracondylar fractures• Any significantly displaced/deformed
fracture
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)
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
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
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
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
Spiral Fracture
• Fracture has a curvilinear course• Common in toddlers• Think abuse in children who are not
walking
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
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
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
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
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
Nursemaid’s Elbow
• Reduction:– Flexion of elbow with supination of the
forearm OR hyperpronation of the forearm
– Return of function within 15 min
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
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
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
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
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!
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!!
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
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
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
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
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
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
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
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
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
Poison Management
• Exam– ABCs– HR, RR, Blood pressure– Neuro status– Pupillary exam (key to some
toxidromes)– Breath odor– Skin: temp, color, diaphoresis
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
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
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
GI Decontamination
• Ipecac– NOT recommended by the AAP!!– No home use
GI Decontamination
• Activated charcoal– Most commonly used method– Adsorbs the ingested substance– Dose = 1gram/kg– Most benefit if given within 1 hr of
ingestion
GI Decontamination
• Activated charcoal– Complications
• Pulmonary aspiration• Emesis• Constipation or intestinal obstruction
– Contraindications• Hydrocarbons or corrosives• Ileus• Compromised airway/ altered mental status
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
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
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)
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
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
GI Decontamination
• Whole bowel irrigation– Contraindications
• Bowel perforation• Bowel obstruction• Ileus• Compromised airway/ altered mental status• Hemodynamic instability• Intractable vomiting
Tox Mnemonics
• Miosis (small pupils) = COPS– C cholinergics, clonidine– O opiates, organophosphates– P phenothiazine, pilocarpine,
physostigmine– S sedatives (barbituates)
Tox Mnemonics
• Mydriasis (dilated pupils) = AAAS– A antihistamine– A antidepressant– A anticholinergic, atropine– S sympathomemetics (amphetamine,
cocaine, PCP)
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
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
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
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)
Tox Mnemonics
• Increased osmolar gap= MAD GAS– M mannitol– A alcohols and glycols – D diatrizoate (iodine contrast agent)– G glycerol– A acetone– S sorbitol
Tox Mnemonics
• Hypoglycemia = HOBIES– H hypoglycemia– O oral hypoglycemics– B beta blockers– I insulin– E ethanol– S salicylates
Pharmaceutical Ingestions
• Content specifications for specific substances– Acetaminophen Salicylates– Anticholinergics Theophylline– Clonidine Tricyclic
Antidepressants– Ibuprofen– Iron– Opiates– Phenothiazines
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)
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
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
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
Acetaminophen
• Rumack-Matthew nomogram
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
Anticholinergics
• Blocks acetylcholine (ACH) at muscarinic receptors
• Examples– Atropine Belladona– Antihistamines Muscle relaxants– Phenothiazines Mushrooms– TCAs Jimson weed
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
Anticholinergics
• Treatment– Activated charcoal if good mental status– Supportive care– Physostigmine
• Reversibly inhibits cholinesterases and allows ACH to accumulate
• Use is controversial
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
Clonidine
• Signs/ Symptoms– Lethargy– Miosis (remember COPS)– Bradycardia– Apnea– Coma– Hypotension– ***May cause transient
HYPERtension****
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
Ibuprofen
• Causes anion gap metabolic acidosis• Renal failure• Coma or seizures (rare)
• Treatment– Activated charcoal– Supportive care– Monitor renal function and acid/base
status
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
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
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
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
Iron
• Therapy adjuvants– Whole bowel irrigation– Endoscopic gastric pill removal– Do NOT use ipecac, gastric lavage – Activated charcoal does NOT bind iron
Opiates
• Most cases present from drug abuse• Acts on receptors in the brain• Ex: Morphine, heroin, methadone,
codeine, meperidine
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
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
Phenothiazines
• Promethazine, prochlorperazine, chlorpromazine (antipsychotics)
• Symptoms– Anticholinergic symptoms– CNS depression– Hypotension– **Transient HYPERtension**– Cogwheel rigidity– Dystonic reaction: neck spasms, tongue
protrusion, oculogyric crisis
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***
Salicylates
• Aspirin, oil of wintergreen, antidiarrheal products
• Pathophys: uncouples oxidative phosphorylation
• Acute toxic dose: 150mg/kg
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
Salicylates
• Diagnosis– Levels >30 mg/dL potentially toxic– Levels > 40mg/dL symptomatic– Levels >100mg/dL serious toxicity– Serially monitor levels– Labs: ABG, electrolytes, coags
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
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
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
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!!
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**
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
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
Environmental Ingestions
• Content specifications for specific substances– Carbon monoxide Plants– Acids/Alkali
Esophageal FB– Hydrocarbons– Ethanol– Methanol– Ethylene glycol– Organophosphates
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
Carbon Monoxide
• Symptoms– Headache– Dizziness– Nausea, vomiting– Visual changes– Weakness– Syncope– Ataxia– Seizures, coma death
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
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
Caustic Ingestions
• Signs and symptoms– Drooling– Refusal to drink– Vomiting– Oral burns– Dysphagia– Stridor or resp distress– Chest or abdominal pain
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
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**
Caustic Ingestions
• Complications– Necrosis– Esophagitis– Perforation– Stricture formation
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!!
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
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)
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
Hydrocarbon Ingestion
• DO NOT:– Use ipecac– Gastric lavage– Activated charcoal– Steroids– Prophylactic antibiotics – Epinephrine
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)
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.
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
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
Methanol
• Labs– Methanol level– Elevated osmolar gap– Elevated anion gap (anion gap
acidosis)
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)
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)
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
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
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)
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
Organophosphates
• Symptoms: SLUDGE & DUMBELS• Nicotinic symptoms
– Muscle twitching, weakness, tremors– Respiratory weakness– Confusion– Coma– Slurred speech– Seizures– Altered mental status
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
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
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)
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)
Esophageal Foreign Bodies
• Signs/ Symptoms– 30% asymptomatic (take all seriously)– Drooling– Dysphagia– Choking, gagging, vomiting– Cough, stridor, wheezing, dyspnea– Pain in neck, throat, chest
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
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
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)
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
Lacerations/Wounds
• Wound management– Hemostasis– History of wound mechanism– Tetanus immunization history– Thorough wound cleaning– Remove debris– Debride devitalized tissue– Closure of wound
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
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
Lacerations/Wounds
• Laceration complications– Tendon laceration– Arterial damage– Infection– Limited movement due to scar
formation– Scarring– Keloid formation
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)
Puncture Wounds
• Common causes of infection– Staphylococcus– Streptococcus– Pseudomonas (esp if puncture wound
through a sneaker)
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
Pathologist on TrialDuring 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.