Emergency Medicine

Question 1

Bites:

• Cats: ____, _____
• Dogs: ____, ____, Capnocytophaga canimorsus
• Human: Aerobic, anaerobic (Eikenella)
• Puncture: _____ species
• Primary closure on the following bites:
  
  • ____ if <24 hours old, other anatomic locations if ___ hours, wounds in immunocompromised

Healing by secondary intention given high risk of infection:
- ____ and ____, ___ injuries, ____ wounds, wounds >___ hours, wounds in immunocompromised

• Prophylaxis therapy should be routinely initiated in those with
  
  • Moderate or severe bite wounds (esp if edema or crush injury present)
  • ____ wounds
  • ____ injuries
  • Deep or surgically closed facial wounds
  • Wounds involving the face, hands, feet, wounds, or genital area
  • Wounds sustained by immunocompromised and/or asplenic patients or wounds with signs of infection
  • _____ bites
• In simple mammalian bites, there is clear evidence that prophylactic antibiotics decrease infection only for bites to the hand.
• Abx
  
  • 1st ilne is ______ for 7-10 days
  • With nonimmediate hypersensitivity reactions to penicillin: Tx with PO ______
  • Allergic reactions to B-lactam antibiotics:
    
    • ____ plus _____ or ______
    • > 8yo: ____
    • > 18yo: ____
  • For puncture wounds: _____
  • For IV antibiotic therapy: ______

Answer 1

Bites:

• Cats: Pasteurella, Staph aureus
• Dogs: Pasteurella, Staph aureus, Capnocytophaga canimorsus
• Human: Aerobic, anaerobic (Eikenella)
• Puncture: Pseudomonas species
• Primary closure on the following bites:
  
  • Face if <24 hours old, other anatomic locations if <12 hours old and clinically uninfected
• Healing by secondary intention given high risk of infection:
  
  • Hands and feet, crush injuries, puncture wounds, wounds >12 hours, wounds in immunocompromised
• Prophylaxis therapy should be routinely initiated in those with
  
  • Moderate or severe bite wounds (esp if edema or crush injury present)
  • Puncture wounds, esp with penetration of bone(s), tendon sheath(s), or joint(s) (all cat bites)
  • Crush injuries
  • Deep or surgically closed facial wounds
  • Wounds involving the face, hands, feet, wounds, or genital area
  • Wounds sustained by immunocompromised and/or asplenic patients or wounds with signs of infection
  • Human bites
• In simple mammalian bites, there is clear evidence that prophylactic antibiotics decrease infection only for bites to the hand.
• Abx
  
  • 1st ilne is amoxicillin-clavulanate for 7-10 days
  • With nonimmediate hypersensitivity reactions to penicillin: Tx with PO 3rd generation cephalosporin, cefixime, or cefpodoxime
  • Allergic reactions to B-lactam antibiotics:
    
    • TMP-SMX plus clindamycin or azithromycin
    • > 8yo: doxycycline
    • > 18yo: levofloxacin
  • For puncture wounds: ciprofloxacin
  • For IV antibiotic therapy: ampicillin

Question 2

Hymenoptera stings (Bees, wasps, and ants)

• Tx: Remove stinger by ______ or using _____
• If bee sting with _______ from sting, must go to ED

Answer 2

Hymenoptera stings (Bees, wasps, and ants)

• Tx: Remove stinger by gently scraping skin (finger or card) or using tweezers
• If bee sting with hives (not just a localized reaction) <2 hours from sting, must go to ED

Question 3

Black widow spider (_____ macrons)

• Shiny black with ________ marking on their abdomen
• Pt: ______Painful???? Muscle cramping and fasciculations.
• Tx: ______

Answer 3

Black widow spider (Latrodectus macrons)

• Shiny black with bright red/orange marking on their abdomen
• Pt: Very painful bite. Muscle cramping and fasciculations.
• Tx: Local wound care, analgesia, tetanus prophylaxis. Typically, all symptoms resolve within 24-48 hours
  
  • Tx with analgesic for pain would be the best management

Question 4

Brown recluse spider bite (____ reclusa)
- Adults have dark biotin pattern on the dorsal front portion of the body - “_____” spiders

• Pt:
  
  • Initially ______.
• Over the next day or 2, a _______ develops that progresses to ________.
  
  • Rarely have systemic influenza-like symptoms such as fever, chills, nausea, vomiting; children can occasionally develop ______ (systemic loxoscelism)
• Tx:
  
  • Bite with no necrosis or necrosis <2cm: _______
  • Supportive: ______
    - Although controversial, _______ has been used to help reduce necrosis associated with brown recluse bites when given in the 1st 48 hours.
    - Note: _____ is a CI

Answer 4

Brown recluse spider bite (Loxosceles reclusa)
- Adults have dark biotin pattern on the dorsal front portion of the body - “fiddleback or violin” spiders

• Pt:
  
  • Initially painless/unnoticed. Present with red plaque that has central pallor. Pain will intensify at site 2-8 hours later; this can be severe at times. Over the next day or 2, a hemorrhagic blister develops that progresses to necrotic ulceration (cutaneous loxoscelism).
    
    • A) Self limited lesion with minor local reaction that resolves within a week
    • B) Develop an eschar which ultimately can become necrotic and ulcerated (aka cutaneous loxoscelism)
  • Rarely have systemic influenza-like symptoms such as fever, chills, nausea, vomiting; children can occasionally develop hemolysis (systemic loxoscelism)
• Tx:
  
  • Bite with no necrosis or necrosis <2cm: Local wound care and observation
  • Supportive: Oral analgesia, updating tetanus, cleansing the wound
  • For evidence of necrosis:
    
    • Necrotic wound is self-limiting
    • Dapsone and steroids are controversial bc data on effectiveness is lacking
      
      • Although controversial, Dapsone has been used to help reduce necrosis associated with brown recluse bites when given in the 1st 48 hours.
        
        • Note: G6PD is a CI to dapsone

Question 5

Snake bites

• > 95% of poisonous snake bites are from pit vipers
  • ___ on ___, kill a fellow; ___ on ___, venom lack
• Pt:
  
  • Local tissue effects as well as systemic toxicity, including swelling and ecchymosis, necrosis, compartment syndrome
  • Many children have been bitten by nonvenomous snakes or have “dry bite” by venomous snake
    
    • Dry bites have little or no local swelling and no systemic symptoms. Watch asymptomatic pts with no lab abnormalities for 6 hours (24 hours for LE bites).
• Tx:
  
  • Immobilize the body part
    
    • Do NOT _________
  • Possible IVF and analgesia to pts with symptomatic envenomation.
  • Antivenin based on severity of bite
    
    • Swelling extending beyond a joint
    • Abnormal labs
    • Shock

Answer 5

Snake bites

• > 95% of poisonous snake bites are from pit vipers
  • Red on yellow, kill a fellow; red on black, venom lack
• Pt:
  
  • Local tissue effects as well as systemic toxicity, including swelling and ecchymosis, necrosis, compartment syndrome
  • Many children have been bitten by nonvenomous snakes or have “dry bite” by venomous snake
    
    • Dry bites have little or no local swelling and no systemic symptoms. Watch asymptomatic pts with no lab abnormalities for 6 hours (24 hours for LE bites).
• Tx:
  
  • Immobilize the body part and remove any sources of possible constriction (watches, rings).
    
    • Do NOT apply pressure, ice, tourniquet, not use excision and suction.
  • Possible IVF and analgesia to pts with symptomatic envenomation.
  • Antivenin based on severity of bite
    
    • Swelling extending beyond a joint
    • Abnormal labs
    • Shock

Question 6

Scorpion sting

• Scorpion stings are extremely painful. Can cause local numbness and swelling WITHOUT _______.
• Envenomation can cause various _______, including restlessness, muscular fasciculations, ataxia, and cranial nerve abnormalities such as abnormal eye movements.
• Management:
  
  • ABCs. Analgesia, benzos, assess vaccination status. Antivenom for Centruroides sculpturatus

Answer 6

Scorpion sting

• Scorpion stings are extremely painful. Can cause local numbness and swelling WITHOUT significant erythema.
• Envenomation can cause various neuromuscular symptoms, including restlessness, muscular fasciculations, ataxia, and cranial nerve abnormalities such as abnormal eye movements.
• Management:
  
  • ABCs. Analgesia, benzos, assess vaccination status. Antivenom for Centruroides sculpturatus

Question 7

Jellyfish sting

- To relieve pain, soak in ____.

Answer 7

Jellyfish sting

- To relieve pain, soak in hot water.

Question 8

Bug safety

• > __ mo can use ____% DEET
• Do not use DEET in

Answer 8

Bug safety

• > 2 mo can use 10-30% DEET
• Do not use DEET in <2mo

Question 9

Burns
- Prevention: Set water heater to ____F (48.9-51.7C)

• Classification
  
  • Superficial burns: Injury only to epidermis (__ and __)
  • Partial-thickness burns: Injury to epidermis and dermis (__ and __)
  • Full-thickness burns: Injury to the epidermis and entire dermis (___ and ___)
  • 4th degree: Involves skin, subcutaneous tissue, and underlying structures (muscle, bones)
• BSA
  
  • <14yo: Lund and Browder chart or estimate using child’s hand (1% of BSA). Only _____ and higher burns in estimating the total BSA burned.

Answer 9

Burns
- Prevention: Set water heater to 120-125F (48.9-51.7C)

• Classification
  
  • Superficial burns: Injury only to epidermis (dry and painful)
  • Partial-thickness burns: Injury to epidermis and dermis (moist and painful)
  • Full-thickness burns: Injury to the epidermis and entire dermis (dry and insensate)
  • 4th degree: Involves skin, subcutaneous tissue, and underlying structures (muscle, bones)
• BSA
  
  • <14yo: Lund and Browder chart or estimate using child’s hand (1% of BSA). Only partial-thickness and higher burns in estimating the total BSA burned.

Question 10

Management

• Superficial burn or partial-thickness burn involving <5% of TBSA: Tx as outpatient
  
  • Cleanse.
  • Leave blisters intact if <2cm iron thick-skinned areas such as palms/soles. Debride if ruptured.
  • Wound should be dressed with topical antimicrobial agents (silver sulfadiazine or bacitracin)
• Major burn care:
  
  • Estimate IVF requirements using the Parkland formula for burns >15% of BSA 2nd and 3rd degree PLUS regular maintenance fluids
    
    • Parkland formula = ____ x ____ x____ = mL
      
      • Over the first 24 hours: _______
    • PLUS maintenance fluids using Holliday method: 4ml/kg for 0-10kg, 2ml/kg for 11-20kg, and 1ml/kg for >20kg = ml/hr
    • Add 2 values to get total ml/hr
• American Burn Association Burn Center Transfer Criteria:
  
  • Partial thickness burns >____% TBSA
  • Burns that involve the _________
  • 3rd degree burns in any age group
  • Electrical burns, including lightning injury
  • Chemical burns
  • Inhalation injury
  • Burn injury in pts with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality
  • Any pts with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality.
  • Hospitals without qualified personnel or equipment for the care of children should transfer children with burns to a burn center with these capabilities
• Antibiotics for evidence of active infection. The best indicator for starting parenteral antibiotics is discoloration of wound edges.
• Complications
  
  • Hypermetabolic state that can last up to 12 months after injury. Aggressive nutritional support.
    
    • High ____ formula supplemented with vitamins C and A and zinc sulfate to provide above REE is the best nutritional plan to provide appropriate calories and nutrition for promotion of optimal wound healing.
  • Hypo____and hypo___.

Answer 10

Management

• Superficial burn or partial-thickness burn involving <5% of TBSA: Tx as outpatient
  
  • Cleanse.
  • Leave blisters intact if <2cm iron thick-skinned areas such as palms/soles. Debride if ruptured.
  • Wound should be dressed with topical antimicrobial agents (silver sulfadiazine or bacitracin)
• Major burn care:
  
  • Estimate IVF requirements using the Parkland formula for burns >15% of BSA 2nd and 3rd degree PLUS regular maintenance fluids
    
    • Parkland formula = % BSA (2nd or 3rd degree burns) x 4ml/kg x kg body weight = mL
      
      • Over the first 24 hours: 50% fluid given in first 8 hours, 50% given in next 16 hours
    • PLUS maintenance fluids using Holliday method: 4ml/kg for 0-10kg, 2ml/kg for 11-20kg, and 1ml/kg for >20kg = ml/hr
    • Add 2 values to get total ml/hr
• American Burn Association Burn Center Transfer Criteria:
  
  • Partial thickness burns >10% TBSA
  • Burns that involve the face, hands, feet, genitalia, perineum, and major joints
  • 3rd degree burns in any age group
  • Electrical burns, including lightning injury
  • Chemical burns
  • Inhalation injury
  • Burn injury in pts with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality
  • Any pts with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality.
  • Hospitals without qualified personnel or equipment for the care of children should transfer children with burns to a burn center with these capabilities
• Antibiotics for evidence of active infection. The best indicator for starting parenteral antibiotics is discoloration of wound edges.
• Complications
  
  • Hypermetabolic state that can last up to 12 months after injury. Aggressive nutritional support.
    
    • High protein formula supplemented with vitamins C and A and zinc sulfate to provide above REE is the best nutritional plan to provide appropriate calories and nutrition for promotion of optimal wound healing.
  • Hypocalcemia and hypomagnesemia. Hypocalcemia can cause CHF.

Question 11

Electrical burns

• DC electricity: Tends to cause a single muscle contraction
• AC exposure: More dangerous than DC at same voltage bc alternating nature of the current causes tetany, preventing the victim from releasing the contracted muscles and prolonging the exposure.
• Tx:
  
  • High-voltage electrical burns can cause asystole, ventricular fibrillation, chest-wall tetany, central respiratory failure, surface thermal burns, and deep tissue injury, leading to compartment syndrome, myoglobin release, rhabdomyolysis, and renal failure.
  • Give IVF and check electrolytes, urinalysis, serum myoglobin, serum CK, and EKG.
  • ______ may be indicated if rhabdomyolysis is present and the urine pH is low.
  • High voltage exposures require _____for 24-48 hours.

Answer 11

Electrical burns

• DC electricity: Tends to cause a single muscle contraction
• AC exposure: More dangerous than DC at same voltage bc alternating nature of the current causes tetany, preventing the victim from releasing the contracted muscles and prolonging the exposure.
• Tx:
  
  • High-voltage electrical burns can cause asystole, ventricular fibrillation, chest-wall tetany, central respiratory failure, surface thermal burns, and deep tissue injury, leading to compartment syndrome, myoglobin release, rhabdomyolysis, and renal failure.
  • Give IVF and check electrolytes, urinalysis, serum myoglobin, serum CK, and EKG.
  • Urine alkalinization may be indicated if rhabdomyolysis is present and the urine pH is low.
  • High voltage exposures require cardiac monitoring for 24-48 hours.

Question 12

Drowning
- ______ is the leading cause of morbidity and mortality during drowning

• Prevention:
  
  • AAP supports _____
  • AAP does recommend _____
• In pts who survive the initial insult, _______ can result
• Occasionally, ______ drowning victims can have preserved neurologic function.
• Management
  
  • On the scene, ventilation is the most important intervention, followed by chest compressions if pulseless
  • Pts who have. GCS >___ and initial oxygen saturation >___% are considered low risk. However, observation for 4-6 hours after the event is warranted.
  • Continue resuscitation until core body temp is rewarmed to at least _____C (86-89C)
• RF:
  
  • Extended submersion times >____ mins - the most critical prognostic factor is the duration of submersion.
  • Prolonged resuscitation >____ mins
  • Age >___
  • Glasgow Coma Score ___ mins
  • Persistent apnea and CPR in ED
  • Arterial blood pH <7.1 at presentation
  • Illicit drug or alcohol use preceding the event

Answer 12

Drowning
- Cerebral hypoxia is the leading cause of morbidity and mortality during drowning

• Prevention:
  
  • AAP supports installation of a 4-sided fence that isolated the house and yard that is at least 1.22m (4ft) high
  • AAP does recommend consistent use of personal flotation device (lifejackets).
• In pts who survive the initial insult, ARDS or acute lung injury can result from water in the alveoli washing out surfactant.
• Occasionally, hypothermia drowning victims can have preserved neurologic function.
• Management
  
  • On the scene, ventilation is the most important intervention, followed by chest compressions if pulseless
  • Pts who have. GCS >13 and initial oxygen saturation >95% are considered low risk. However, observation for 4-6 hours after the event is warranted.
  • Continue resuscitation until core body temp is rewarmed to at least 30-32C (86-89C)
• RF:
  
  • Extended submersion times >6 mins - the most critical prognostic factor is the duration of submersion.
  • Prolonged resuscitation >25 mins
  • Age >14
  • Glasgow Coma Score <5
  • Lack of early bystander CPR >10 mins
  • Persistent apnea and CPR in ED
  • Arterial blood pH <7.1 at presentation
  • Illicit drug or alcohol use preceding the event

Question 13

Epidural hematoma

• Blood between skull/peritosteum and dura
• Path:
  
  • Temporal bone fracture, which causes a tear of the middle meningeal artery
  • More commonly in children, a tear in the bridging veins or dural sinuses
• Pt: Brief loss of consciousness by trauma followed by ____ period and then deterioration.
• CT scan: ____ shaped hematoma that does not cross suture lines.
• Tx: Surgical intervention is always indicated.

Answer 13

Epidural hematoma

• Blood between skull/peritosteum and dura
• Path:
  
  • Temporal bone fracture, which causes a tear of the middle meningeal artery
  • More commonly in children, a tear in the bridging veins or dural sinuses
• Pt: Brief loss of consciousness by trauma followed by lucid period (regains consciousness over several hours) and then deterioration.
• CT scan: Lens shaped (biconvex or lentiform) hematoma that does not cross suture lines.
• Tx: Surgical intervention is always indicated.

Question 14

Subdural hematoma

• Path: Tearing of the intracranial bridging veins, which drain the brain parenchyma into the dural cerebral venous sinuses.
• CT scan: ____ shaped. Free to extend across suture lines and cause a more linear concave finding
• Tx: Seek neurosurgical consultation

Answer 14

Subdural hematoma

• Path: Tearing of the intracranial bridging veins, which drain the brain parenchyma into the dural cerebral venous sinuses.
• CT scan: Crescent shaped or concavoconvex hematoma. Free to extend across suture lines and cause a more linear concave finding
• Tx: Seek neurosurgical consultation

Question 15

Skull fractures

• In all children <3 years of age, skull XRs are usually done for all but trivial head injury.
• If you suspect an underlying intracranial lesion, order a CT scan with bone windows
  
  • Suspect underlying lesions in any of the following:
    
    • Depressed or comminuted skull fracture
    • LOC >5 mins
    • AMS or irritability
    • Bulging fontanelle
    • Focal neurologic signs or deteriorating neurologic condition
    • Vomiting at least 5x or for >6 hours
    • Nonimpact seizures in children <6 months of age

Linear skull fractures - overlying hematoma, bony abnormalities are rarely palpated

• Tx: Some do not require specific therapy. Advise parents not to restrict the child’s normal activities.
  
  • Repeat skull XR in 3 months to show union. Most heal within 6-12 months.

“Ping-pong” or “pond” fracture

• Children <1 yo have craniums that are not well calcified; thus, bones can be displaced inward without an actual break
• Do not typically require surgical elevation unless they are depressed >0.5cm

Basilar skull fractures - fractures to base of the skull.
- Pt: Bilateral periorbital ecchymosis (“Racoon eyes” or black eyes), Battle sign (ecchymosis over mastoid process), tympanic membrane discoloration if petrous bone of middle fossa involved, hemotympanum, otorrhea, or drainage of CSF from nose (rhinorrhea).

Answer 15

Skull fractures

• In all children <3 years of age, skull XRs are usually done for all but trivial head injury.
• If you suspect an underlying intracranial lesion, order a CT scan with bone windows
  
  • Suspect underlying lesions in any of the following:
    
    • Depressed or comminuted skull fracture
    • LOC >5 mins
    • AMS or irritability
    • Bulging fontanelle
    • Focal neurologic signs or deteriorating neurologic condition
    • Vomiting at least 5x or for >6 hours
    • Nonimpact seizures in children <6 months of age

Linear skull fractures - overlying hematoma, bony abnormalities are rarely palpated

• Tx: Some do not require specific therapy. Advise parents not to restrict the child’s normal activities.
  
  • Repeat skull XR in 3 months to show union. Most heal within 6-12 months.

“Ping-pong” or “pond” fracture

• Children <1 yo have craniums that are not well calcified; thus, bones can be displaced inward without an actual break
• Do not typically require surgical elevation unless they are depressed >0.5cm

Basilar skull fractures - fractures to base of the skull.
- Pt: Bilateral periorbital ecchymosis (“Racoon eyes” or black eyes), Battle sign (ecchymosis over mastoid process), tympanic membrane discoloration if petrous bone of middle fossa involved, hemotympanum, otorrhea, or drainage of CSF from nose (rhinorrhea).

Question 16

Orbital floor fracture

• Path: Occur when small hard round objects directly strike the eye. Linear fracture through the floor of the orbit.
• Sequela: Entrapment of the ____ and orbital fat.
• Pt:
  
  • “Sunken” appearance to the eye on the affected side
  • Asymmetry in the horizontal level of the eye
  • Limitation of ______ on the affected side
• Tx:
  
  • Urgent operative intervention is indicated in children with orbital blowout fractures with muscle entrapment
  • A careful ophtho evaluation
  • Visual acuity should be assessed

Answer 16

Orbital floor fracture

• Path: Occur when small hard round objects directly strike the eye. Linear fracture through the floor of the orbit.
• Sequela: Entrapment of the inferior rectus muscle and orbital fat. Entrapment may lead to ischemia and eventual loss of intraocular muscle function.
• Pt:
  
  • “Sunken” appearance to the eye on the affected side
  • Asymmetry in the horizontal level of the eye
  • Limitation of upward gaze on the affected side due to inferior rectus muscle entrapment
• Tx:
  
  • Urgent operative intervention is indicated in children with orbital blowout fractures with inferior rectus muscle entrapment
  • A careful ophtho evaluation
  • Visual acuity should be assessed

Question 17

Spinal cord injury
- Give IV _____, which has been shown to enhance motor and sensory recovery in adult studies. Never manipulate cervical spine injuries to reduce a fracture.

Answer 17

Spinal cord injury
- Give IV methylprednisolone, which has been shown to enhance motor and sensory recovery in adult studies. Never manipulate cervical spine injuries to reduce a fracture.

Question 18

Blunt abdominal trauma

• ______ is the organ most commonly injured in blunt abdominal trauma; ____ is the next most frequently injured organ
• Patients with seat belt sign after a motor vehicle collision are at significantly increased risk for abdominal injuries as well as Chance fractures (a type of lumbar spine fracture caused by extreme forward flexion, typically over a lap-only seat belt).
• Severely injured patients have associated hypovolemia and hemorrhagic shock, often heralded by tachycardia
  
  • Resuscitate with fluids and blood products
  • Children who sustain blunt abdominal trauma and are hemodynamically unstable require a ______ irrespective of the findings of the FAST exam.
• In a stable pt
  
  • A ____ exam should be performed
  • ______ is best way to determine abdominal injury in stable patient

Answer 18

Blunt abdominal trauma

• Spleen is the organ most commonly injured in blunt abdominal trauma; liver is the next most frequently injured organ
• Patients with seat belt sign after a motor vehicle collision are at significantly increased risk for abdominal injuries as well as Chance fractures (a type of lumbar spine fracture caused by extreme forward flexion, typically over a lap-only seat belt).
• Severely injured patients have associated hypovolemia and hemorrhagic shock, often heralded by tachycardia
  
  • Resuscitate with fluids and blood products
  • Children who sustain blunt abdominal trauma and are hemodynamically unstable require a diagnostic laparotomy irrespective of the findings of the FAST exam.
• In a stable pt
  
  • A FAST exam should be performed
  • CT abdomen is best way to determine abdominal injury in stable patient

Question 19

Splenic injury

• Referred______ pain due to the presence of subphrenic blood with diaphragmatic irritation may be an associated presenting symptom.
• For hemodynamically stable children with suspected splenic injuries, _____ is considered the most sensitive diagnostic tool and best method for evaluating solid organ injury

Answer 19

Splenic injury

• Referred L shoulder pain (Kehr sign) due to the presence of subphrenic blood with diaphragmatic irritation may be an associated presenting symptom.
• For hemodynamically stable children with suspected splenic injuries, CT of the abdomen is considered the most sensitive diagnostic tool and best method for evaluating solid organ injury

Question 20

Compartment syndrome
- Path: Acute compartment syndrome occurs when increased pressure within a fascial structure, often as a result of injury (fracture or burn), leads to compression of intracompartmental vasculature and ischemia, causing subsequent ________ ischemia/damage.

• Pt: 5 P’s- __________
• Biggest clue is _______ to the fracture, esp pain that is remote from the fracture site.

Answer 20

Compartment syndrome
- Path: Acute compartment syndrome occurs when increased pressure within a fascial structure, often as a result of injury (fracture or burn), leads to compression of intracompartmental vasculature and ischemia, causing subsequent nerve and muscle ischemia/damage.

• Pt: 5 P’s- Pain, pallor, pallor, paresthesias, pulselessness, paralysis
• Biggest clue is pain out of proportion to the fracture, esp pain that is remote from the fracture site.

Question 21

lavicle fracture

• Tx: Self-resolving, but can be associated with brachial plexus injury. Almost all clavicle fractures heal well, but warn families about the prominent “lump” of callus that develops as the fracture heals and remodels.
  
  • In a young child: Immobilization of the affected arm (eg sling and swathe)
  • In an older child: Simple sling for 2-3 weeks

Answer 21

lavicle fracture

• Tx: Self-resolving, but can be associated with brachial plexus injury. Almost all clavicle fractures heal well, but warn families about the prominent “lump” of callus that develops as the fracture heals and remodels.
  
  • In a young child: Immobilization of the affected arm (eg sling and swathe)
  • In an older child: Simple sling for 2-3 weeks

Question 22

Salter Harris - fracture involving the growth plate

• Type I = _____
• Type II = ____
• Types III = ____
• Type IV = ____
• Type V = _____

______ are lower-risk fractures for pediatric patient

Fractures that involve the actively growing region are more likely to affect limb lengthening (types ____).

Answer 22

Salter Harris - fracture involving the growth plate
- Type I = Straight across/slip- Across physis only (common, difficult to see on radiograph)
- Type II = Above (most common)
- Types III = Lower or beLow
- Type IV = Two or Through
- Type V = ERasure of growth plate OR cRush OR Rammed together (Difficult to see on radiograph)
Types 1 and 2 are lower-risk fractures for pediatric patient
Fractures that involve the actively growing region are more likely to affect limb lengthening (types 3-5).

Question 23

Seymour fracture

• Salter-Harrison type ____ fracture of the distal phalanx (often the great toe or the fingers).
• Fracture goes through the physis and extends into the metaphysis. Seymour fractures result in displacement of the nail with a laceration under the proximal nail fold; as such, they are actually open fractures.
• Ortho consultation is necessary
  
  • most Seymour fractures will require surgical irrigation, open nail bed repair, and ________ by an orthopedic surgeon.

Answer 23

Seymour fracture

• Salter-Harrison type II fracture of the distal phalanx (often the great toe or the fingers).
• Fracture goes through the physis and extends into the metaphysis. Seymour fractures result in displacement of the nail with a laceration under the proximal nail fold; as such, they are actually open fractures.
• Ortho consultation is necessary
  
  • most Seymour fractures will require surgical irrigation, open nail bed repair, and open reduction and internal fixation (ORIF) by an orthopedic surgeon.

Question 24

Greenstick fracture

• Typical mechanism:_______
• The bony cortex is typically fractured on _____
• Management: Splint and refer to Ortho
  
  • Angulation >15 degrees requires ____, immobilization in a splint, and Ortho f/u
  • If there is no deformation, immobilization alone is effective therapy

Answer 24

Greenstick fracture

• Typical mechanism: Fall onto an outstretched hand.
• The bony cortex is typically fractured on the outer (convex) side of the fracture, while it remains intact on the inner (concave) side.
• Management: Splint and refer to Ortho
  
  • Angulation >15 degrees requires closed reduction, immobilization in a splint, and Ortho f/u
  • If there is no deformation, immobilization alone is effective therapy

Question 25

Torus (Buckle) fracture

• Path: ______
• Dx: _____ on radiograph
• Tx: Usually heals with ___

Answer 25

Torus (Buckle) fracture

• Path: Axial load injury and compression of the bone (eg falling on an outstretched hand) produces a “buckle” of the metaphysis.
• Dx: Small bulging of cortex on radiograph
• Tx: Usually heals with 3 weeks of immobilization.
  
  • Splinting in ER to prevent injury, ortho f/u.

Question 26

Metaphyseal corner fractures “bucket-handle” fractures

• Mechanism: _____
• These fractures should always raise suspicion for _____

Answer 26

Metaphyseal corner fractures “bucket-handle” fractures

• Mechanism: Occur when a child’s extremity is pulled or twisted forcibly, or when a child is shaken
• These fractures should always raise suspicion for child abuse.

Question 27

Nursemaid’s Elbow/Radial Subluxation

• Mechanism: ______
  
  • ______ ligament displacement.
• Pt: Half of children present with arm in classic position - _________
  
  • Swelling around elbow is uncommon. Presence of swelling, bruising, or point tenderness around the elbow should prompt evaluation for UE fracture with radiographs
• Tx: 2 reduction techniques:
  
  • _____ (most effective and less painful).
  • _____

Answer 27

Nursemaid’s Elbow/Radial Subluxation

• Mechanism: Axial traction on forearm with elbow extended (Fall on outstretched hand. Child pulled, lifted, and swing by arm).
  
  • Annular ligament displacement.
• Pt: Half of children present with arm in classic position - elbow somewhat flexed and forearm pronated.
  
  • Swelling around elbow is uncommon. Presence of swelling, bruising, or point tenderness around the elbow should prompt evaluation for UE fracture with radiographs
• Tx: 2 reduction techniques: supination of forearm and flexion of elbow OR hyperpronation of forearm
  
  • Hyperpronation (most effective and less painful).
  • Supination/flexion

Question 28

Distal Humerus/ Supracondylar fracture
- Look for_________ on X-ray, indicating joint effusion/hemarthrosis.

• Complications:
  
  • Displaced supracondylar fractures have a high risk of _______.This is the most serious complication of a supracondylar fracture.
    
    • Untreated, this can lead to _______ in the wrist and hand.
  • Evaluate for damage to the _____.
• Tx: _______

Answer 28

Distal Humerus/ Supracondylar fracture
- Look for posterior fat pad sign on X-ray, indicating joint effusion/hemarthrosis. Sometimes an elbow fracture if difficult to see, and presence of a posterior fat pad (which is normally absent) or displacement of the normally small anterior fat pad is the only clue.

• Complications:
  
  • Displaced supracondylar fractures have a high risk of neurovascular complications, including compartment syndrome of the forearm. This is the most serious complication of a supracondylar fracture.
    
    • Untreated, this can lead to Volkmann ischemic contracture in the wrist and hand.
  • Evaluate for damage to the brachial artery, median nerve, or radial nerve (eg absent or diminished pulse, abnormal motor or sensory function). Monitor neurovascular status carefully with repeat exams.
• Tx: SPLINT ALL SUSPECTED ELBOW FRACTURES (ie localized pain, swelling, joint effusion ) even if no definite fracture is seen, and always arrange ortho follow-up.

Question 29

• Galleazi fracture: _____ fracture

- Monteggia fracture: ____ fracture.

Answer 29

GRUM: galazzi radial, ulnar monteggia

• Galleazi fracture: Dislocation of the distal radioulnar joint in association with a radial fracture
• Monteggia fracture: Dislocation of the proximal radioulnar joint in association with an ulnar fracture.

Question 30

Scaphoid fracture

• Consider a scaphoid fracture whenever a pt presents with tenderness in the “________” after a fall onto an outstretched hand.
• Diagnosis is difficult bc there is often lack of swelling, and plain radiographs (even in multiple views) might be normal.
• Tx:
  
  • _______. Outpatient Ortho referral. Pain medications.

Answer 30

Scaphoid fracture

• Consider a scaphoid fracture whenever a pt presents with tenderness in the “anatomic snuffbox” after a fall onto an outstretched hand.
• Diagnosis is difficult bc there is often lack of swelling, and plain radiographs (even in multiple views) might be normal.
• Tx:
  
  • Immobilize in thumb spica splint (goal is to reduce the complications; even with normal radiograph). Outpatient Ortho referral. Pain medications.

Question 31

Flexor tendon tear (jersey finger)
- Flexor digitorum profundus and flexor digitorum superficialis both contribute to finger flexion

• Asymmetry of finger flexion in the resting position or with attempts at grasping or making a fist is a strong indicator of possible flexor tendon injury.
• Tx??____

Answer 31

Flexor tendon tear (jersey finger)
- Flexor digitorum profundus and flexor digitorum superficialis both contribute to finger flexion

• Asymmetry of finger flexion in the resting position or with attempts at grasping or making a fist is a strong indicator of possible flexor tendon injury.
• Requires prompt referral for urgent evaluation by a hand surgeon within 1 week of injury for improved outcomes.

Question 32

Extensor tendon injury (Mallet finger)
- Path: Rupture of digital portion of extensor tendon caused by forced flexion at the DIP joint

• Tx:
  
  • In contrast to flexor tendon injuries, injuries to the extensor tendons on the dorsal aspect of the fingers often do well with_______ These injuries typically require _______

Answer 32

Extensor tendon injury (Mallet finger)
- Path: Rupture of digital portion of extensor tendon caused by forced flexion at the DIP joint

• Tx:
  
  • In contrast to flexor tendon injuries, injuries to the extensor tendons on the dorsal aspect of the fingers often do well with conservative management. These injuries typically require splinting in extension for 6-12 weeks.
  • Conservative: Splint DIP joint in extension for 6-8 weeks with hand surgery follow-up (splinting of PIP and MCP joints is not necessary)

Question 33

Spiral fracture / Tibial Toddler’s fracture

• Path: __________
  
  • Spiral fractures can be accidental. However, if you see a spiral fracture without an appropriate hx (esp a spiral fracture of the arm or femur), particularly in a nonambulatormetay child, think ______. The exception to this is the “toddler’s fracture,” a spiral fracture of the tibia in a young child. The mechanism is frequently minor - a twist or a jump
• Pt:
  
  • Pt:
  • Limp or refusal to walk.
  • Tenderness to palpation over tibia is often the only sign of toddler fracture.
  • “Child won’t walk right”
• Dx:
  
  • Normal XR.
• Tx:
  
  • Toddler’s fractures typically heal well with immobilization.
    
    • If H&P show signs of toddler fracture, affected leg should be placed in a below-knee walking boot cast and the child should undergo reevaluation about 2 weeks later.

Answer 33

Spiral fracture / Tibial Toddler’s fracture

• Path: Twisting mechanism of injury.
  
  • Spiral fractures can be accidental. However, if you see a spiral fracture without an appropriate hx (esp a spiral fracture of the arm or femur), particularly in a nonambulatormetay child, think abuse.
  • The exception to this is the “toddler’s fracture,” a spiral fracture of the tibia in a young child. The mechanism is frequently minor - a twist or a jump
• Pt:
  
  • Pt:
  • Limp or refusal to walk.
  • Tenderness to palpation over tibia is often the only sign of toddler fracture.
  • “Child won’t walk right”
• Dx:
  
  • Normal XR.
• Tx:
  
  • Toddler’s fractures typically heal well with immobilization.
    
    • If H&P show signs of toddler fracture, affected leg should be placed in a below-knee walking boot cast and the child should undergo reevaluation about 2 weeks later.

Question 34

Chance fracture

- Transverse fractures through _________

Answer 34

Chance fracture
- Transverse fractures through vertebral body that arise most often following motor collisions in which individual was restrained by only a lap belt

Question 35

Sprain (___ to ____)

• Rare in prepubescent children bc the ligament is stronger than the growth plate; thus, younger children get fractures more often than sprains.
• Def: Injury (Stretching or tearing) of a ligament around a joint when it is forced to move in an unnatural position
  
  • Grade 1 = ligament is stretched
  • Grade 2 = partial ligament tear
  • Grade 3 = complete tear of ligament

Strain (____ to ____) = Tearing of muscle fibers of tendon.

Answer 35

Sprain (bone to bone)

• Rare in prepubescent children bc the ligament is stronger than the growth plate; thus, younger children get fractures more often than sprains.
• Def: Injury (Stretching or tearing) of a ligament around a joint when it is forced to move in an unnatural position
  
  • Grade 1 = ligament is stretched
  • Grade 2 = partial ligament tear
  • Grade 3 = complete tear of ligament

Strain (muscle to bone) = Tearing of muscle fibers of tendon.

Question 36

Inversion ankle injuries

- Most common ligament?????

Answer 36

Inversion ankle injuries

- Anterior tibiofibular ligament

Question 37

Overuse injury

• Rotator cuff injury = shoulder overuse injury
• Overuse injury: First step in returning to sport after overuse injury is a ________. Patients should _______. The average return to play time for overuse injuries of the UE is _____ weeks.

Answer 37

Overuse injury

• Rotator cuff injury = shoulder overuse injury
• Overuse injury: First step in returning to sport after overuse injury is a complete resolution of pain at rest and return of full ROM, both actively and passively. Patients should begin a structured rehabilitation program that is stepwise, featuring a gradual return to activity that caused the injury. During this rehabilitation, patients should be monitored for recurrence of pain bc any reappearance of pain warrants further rest and a delay of full return. The average return to play time for overuse injuries of the UE is 8-12 weeks.

Question 38

“Stinger” or “Burner” (Transient upper brachial plexus neuropraxia)

• Transient phenomenon that occurs (most often during a tackle in contact sports) when there is a neck injury resulting in either compression or traction of the ________.
  
  • 3 possible mechanisms of injury
    
    • 1. Contralateral lateral flexion of the neck, resulting in brachial plexus traction
    • 2. Direct blow to lateral neck
    • 3. Hyperextension and ipsilateral lateral flexion, resulting in compression of the brachial plexus
• Pt:
  
  • Unilateral radiation pain, often immediately and radiates circumferentially down the arm.
  • Resolves promptly with or without weakness with normal neurologic findings
  • An injured player will often come off the field actively shaking the involved arm.
• Management:
  
  • Can return to play immediately

Answer 38

“Stinger” or “Burner” (Transient upper brachial plexus neuropraxia)

• Transient phenomenon that occurs (most often during a tackle in contact sports) when there is a neck injury resulting in either compression or traction of the upper brachial plexus / lower cervical spine.
  
  • 3 possible mechanisms of injury
    
    • 1. Contralateral lateral flexion of the neck, resulting in brachial plexus traction
    • 2. Direct blow to lateral neck
    • 3. Hyperextension and ipsilateral lateral flexion, resulting in compression of the brachial plexus
• Pt:
  
  • Unilateral radiation pain, often immediately and radiates circumferentially down the arm.
  • Resolves promptly with or without weakness with normal neurologic findings
  • An injured player will often come off the field actively shaking the involved arm.
• Management:
  
  • Can return to play immediately

Question 39

Acromioclavicular joint sprain
- Mechanism of injury: Blow to the AC joint or a fall onto the lateral aspect of the shoulder. Typically occur in adolescents or adults who participate in collision sports (football, rugby, hockey)

• Tx:
  
  • Lower-grade injuries: Rest, sling for comfort, range-of-motion exercises once pain has abated
    
    • Type 1: Heal within 1-2 weeks
    • Type 2 and 3: Take 1-3 months to heal
  • High-grade injuries with a large degree of clavicular displacement (Types 4-6) often require surgical treatment. Refer to ortho

Answer 39

Acromioclavicular joint sprain
- Mechanism of injury: Blow to the AC joint or a fall onto the lateral aspect of the shoulder. Typically occur in adolescents or adults who participate in collision sports (football, rugby, hockey)

• Tx:
  
  • Lower-grade injuries: Rest, sling for comfort, range-of-motion exercises once pain has abated
    
    • Type 1: Heal within 1-2 weeks
    • Type 2 and 3: Take 1-3 months to heal
  • High-grade injuries with a large degree of clavicular displacement (Types 4-6) often require surgical treatment. Refer to ortho

Question 40

Anterior shoulder dislocation (most common shoulder dislocation)
- Path: Extreme________ or a forceful blow that occurs during sports or from a fall are typical causes.

• Tx: Closed reduction.
  
  • Attempted reduction of dislocated shoulder should be performed as early as possible since muscle spasm sets in shortly after dislocation.
  • Radiographs 3-view shoulder series XR should be obtained after reduction to rule out associated fractures that might demand specific treatment.

Answer 40

Anterior shoulder dislocation (most common shoulder dislocation)
- Path: Extreme external rotation or a forceful blow that occurs during sports or from a fall are typical causes.

• Tx: Closed reduction.
  
  • Attempted reduction of dislocated shoulder should be performed as early as possible since muscle spasm sets in shortly after dislocation.
  • Radiographs 3-view shoulder series XR should be obtained after reduction to rule out associated fractures that might demand specific treatment.

Question 41

Ottawa Anke rules

Answer 41

Ottawa Anke rules

• Bone tenderness at the posterior edge of the distal 6cm or the tip of the lateral malleolus
• Bone tenderness at the posterior edge of the distal 6cm or the tip of medial malleolus
• Bone tenderness at the navicular bone
• Bone tenderness at the base of the 5th metatarsal
• inability to bear weight for at least 4 steps both immediately after injury and at the time of evaluation

Question 42

Female Athlete Triad

• Caloric intake is insufficient to support both healthy physiologic function and the combination of:
  
  • _____________
  • _____________
  • ____________-
• Hx of menstrual dysfunction is the earliest symptom and should prompt obtaining detailed hx of diet, supplements, exercise, and fractures
• Work-up
  
  • Evaluate bone mineral density with _____ in patients with ______ and history of >______.
  • Recommendations for bone densitometry in female athletes at risk for female athlete triad:
    
    • See Table in Doc

Answer 42

Female Athlete Triad

• Caloric intake is insufficient to support both healthy physiologic function and the combination of:
  
  • Energy deficiency (typically from disordered eating)
  • Menstrual dysfunction
  • Low bone mineral density
• Hx of menstrual dysfunction is the earliest symptom and should prompt obtaining detailed hx of diet, supplements, exercise, and fractures
• Work-up
  
  • Evaluate bone mineral density with DXA in patients with <6 menses in 12 months and history of >2 stress fractures.
  • Recommendations for bone densitometry in female athletes at risk for female athlete triad:
    
    • See Table in Doc

Question 43

Abuse

• Fractures that have high specificity for abuse:
  
  • Fractures usually seen only with major trauma (eg vertebral spinous process, sternum, pelvis, scapulae) or that indicate a twist mechanism (spiral fracture of humerus), or if the patienTs’ developmental stage makes the fracture unlikely.
    
    • Sternal fractures
    • Scapula fractures
    • Spinous process fractures
    • Spiral fractures by themselves are not diagnostic of abuse bc they can occur with various injuries involving a twisting mechanism, but spiral fractures other than the classic toddler’s fracture of the tibia should raise concern for abuse if the hx does not seem consistent with the injury.
    • Rib fractures (esp posteriomedial ribs) (resulting from squeezing/shaking)
    • Classic metaphyseal lesions (corner/bucket handle) fractures
    • Femur fractures
      
      • A spiral fracture of the LE, esp of the femur, in a child who is non-ambulatory is usually due to inflicted trauma
• Skeletal survey is mandatory for all children less than ___ years old or with disability/developmental impairments (total of 21 X-rays). Skeletal survey is rarely needed for >5 years old as most can communicate pain.

Answer 43

Abuse

• Fractures that have high specificity for abuse:
  
  • Fractures usually seen only with major trauma (eg vertebral spinous process, sternum, pelvis, scapulae) or that indicate a twist mechanism (spiral fracture of humerus), or if the patienTs’ developmental stage makes the fracture unlikely.
    
    • Sternal fractures
    • Scapula fractures
    • Spinous process fractures
    • Spiral fractures by themselves are not diagnostic of abuse bc they can occur with various injuries involving a twisting mechanism, but spiral fractures other than the classic toddler’s fracture of the tibia should raise concern for abuse if the hx does not seem consistent with the injury.
    • Rib fractures (esp posteriomedial ribs) (resulting from squeezing/shaking)
    • Classic metaphyseal lesions (corner/bucket handle) fractures
    • Femur fractures
      
      • A spiral fracture of the LE, esp of the femur, in a child who is non-ambulatory is usually due to inflicted trauma
• Skeletal survey is mandatory for all children <2 years old or with disability/developmental impairments (total of 21 X-rays). Skeletal survey is rarely needed for >5 years old as most can communicate pain.

Question 44

Sexual abuse

• _________ can be a sign of sexual abuse in children
• RFs:
  
  • The greatest risk for child sexual abuse is _________
  • <4 yo
  • Developmental delay
  • Nonverbal or minimally verbal
  • Chronic illness
  • Household members with psychiatric illnesses and/or substance abuse.
• If the event occurred less than ___ hours before the time of disclosure, encourage the adolescent to consent to undergo a medical and sexual forensic examination.
• Postexposure prophylaxis
  
  • HIV offered up to 72 hours after assault: 3 drug regimen (eg tenofovir-emtricitabine with raltegravir) for 28 days
  • Hepatitis B: Hepatitis B vaccine +/- hepatitis B immune globulin
  • Empiric treatment for:
    
    • Chlamydia: azithromycin 1g oral once (or doxycycline 100mg oral 2x daily for 7 days)
    • Gonorrhea: ceftriaxone 250mg IM once (or cefixime 400mg PO once)
    • Trichomonas vaginalis: metronidazole 2g oral once
  • Human papillomavirus immunization (if survivor has not previously been immunized)

Answer 44

Sexual abuse

• Condylomata acuminata can be a sign of sexual abuse in children
• RFs:
  
  • The greatest risk for child sexual abuse is family structure- living in a single parent family
  • <4 yo
  • Developmental delay
  • Nonverbal or minimally verbal
  • Chronic illness
  • Household members with psychiatric illnesses and/or substance abuse.
• If the event occurred <72 hours before the time of disclosure, encourage the adolescent to consent to undergo a medical and sexual forensic examination.
• Postexposure prophylaxis
  
  • HIV offered up to 72 hours after assault: 3 drug regimen (eg tenofovir-emtricitabine with raltegravir) for 28 days
  • Hepatitis B: Hepatitis B vaccine +/- hepatitis B immune globulin
  • Empiric treatment for:
    
    • Chlamydia: azithromycin 1g oral once (or doxycycline 100mg oral 2x daily for 7 days)
    • Gonorrhea: ceftriaxone 250mg IM once (or cefixime 400mg PO once)
    • Trichomonas vaginalis: metronidazole 2g oral once
  • Human papillomavirus immunization (if survivor has not previously been immunized)

Question 45

Acetaminophen
Toxic metabolite is ________

1 (0-24h):
2 (24-72h):
3 (72-96h):
4 (4-14 days):

ABCs. Within 1 hour, activated charcoal.

Tx: _________- do not delay in substantial overdose or delayed presentation

Check Acetaminophen level ____ hours after ingestion. Level is correlated on the Rumack-Matthew normogram (do not use nomogram if multiple ingestions were ingested)

Indications for NAC
- 
-
- 
- 
DO follow ALT, AST, and PT/INR levels

Answer 45

Acetaminophen
Toxic metabolite is NAPQI

1 (0-24h): Nausea/vomiting, asymptomatic, normal LFTs
2 (24-72h, latent period): RUQ pain. Increased liver enzymes, prolonged PT, elevated INR
3 (72-96h, hepatic failure): Peak of symptoms. Fulminant hepatic failure, coagulopathy, multisystem organ failure
4 (4-14 days): Recovery or death

ABCs. Within 1 hour, activated charcoal.

Tx: N-acetylcysteine- do not delay in substantial overdose or delayed presentation

Check Acetaminophen level 4 hours after ingestion. Level is correlated on the Rumack-Matthew normogram (do not use nomogram if multiple ingestions were ingested)

Indications for NAC
- Serum acetaminophen above treatment line in normogram in acute ingestion (treatment line starts at 150ug/ml)
-
Suspected single ingestion >150mg/kg.

- Unknown time since ingestion and tylenol level >10mg/L
- Lab evidence of hepatotoxicity following tylenol ingestion

DO follow ALT, AST, and PT/INR levels

Question 46

Amphetamines

Synthetic cathinone “bath salt” = amphetamine analog sold as tablet/white powder
Methamphetamine (aka Ice)
Ecstasy (3,4-methylene-dioxymethamphetamine, or MDMA) (aka molly)

Sympathetic hyperstimulation: Tachycardia, HTN, hyperpyrexia, mydriasis, diaphoresis, CNS/behavioral effects (anxiety, agitation, seizures, delusions)

ABCs.
________ to tx psychomotor agitation and seizures
Within 1 hour, activated charcoal

Answer 46

Amphetamines

Synthetic cathinone “bath salt” = amphetamine analog sold as tablet/white powder
Methamphetamine (aka Ice)
Ecstasy (3,4-methylene-dioxymethamphetamine, or MDMA) (aka molly)

Sympathetic hyperstimulation: Tachycardia, HTN, hyperpyrexia, mydriasis, diaphoresis, CNS/behavioral effects (anxiety, agitation, seizures, delusions)

ABCs.
Benzodiazepine to tx psychomotor agitation and seizures
Within 1 hour, activated charcoal

Question 47

Anticholinergics

Antihistamines (eg diphenhydramine, chlorpheniramine)
Antipsychotics
TCAs
Antispasmodics
Some anti-Parkinson agents
A\_\_\_\_\_\_\_\_\_
Some OTC sleep medications
Toxic plants (eg certain mushrooms, jimson weed, deadly nightshade, angel trumpet flowers)

“Mad as a hatter, blind as a bat, dry as a bone, red as a beet”

Supportive care

_________ is controversial but some rec.
• Do NOT give for ______ poisoning bc of high risk of seizures and serious arrhythmias.

• Although reverses CNS effects, it is short-lived and is usually used to diagnose an undifferentiated ingestion as anticholinergic rather than as definitive tx


______ for sedation to mitigate symptoms

Answer 47

Anticholinergics

Antihistamines (eg diphenhydramine, chlorpheniramine)
Antipsychotics
TCAs
Antispasmodics
Some anti-Parkinson agents
Atropine
Some OTC sleep medications
Toxic plants (eg certain mushrooms, jimson weed, deadly nightshade, angel trumpet flowers)

“Mad as a hatter, blind as a bat, dry as a bone, red as a beet”

Supportive care

Physostigmine (reversible cholinesterase inhibitor) is controversial but some rec.
• Do NOT give for TCA poisoning bc of high risk of seizures and serious arrhythmias.

• Although reverses CNS effects, it is short-lived and is usually used to diagnose an undifferentiated ingestion as anticholinergic rather than as definitive tx


Benzodiazepine for sedation to mitigate symptoms

Question 48

Anticholinesterases

Tx: _____

Answer 48

Anticholinesterases

Tx: Atropine

Question 49

Benzodiazepines

Oversedation, respiratory depression, nystagmus, ataxia.
Normal vital signs and pupils

Tx: ______
Exception??____

Answer 49

Benzodiazepines

Oversedation, respiratory depression, nystagmus, ataxia.
Normal vital signs and pupils

Tx: Flumazenil
HOWEVER FLUMAZENIL CAN INDUCE SEIZURES, SO IF GAVE BENZO FOR SEIZURE, SHOULD NOT USE FLUMAZENIL

Question 50

Beta blockers

CNS depression, hypo_____ bradycardia, hypotension, arrhythmias

ONE PILL CAN KILL

Tx: ______
If needed, IV dextrose

Answer 50

Beta blockers

CNS depression, hypoglycemia, bradycardia, hypotension, arrhythmias

ONE PILL CAN KILL

Tx: Glucagon
If needed, IV dextrose

Question 51

Calcium channel blockers (Diltiazem, verapamil)

Hypotension and bradycardia.
Unlike B-blockers, can cause _____ and without _____.

ONE PILL CAN KILL

Tx: ______

Answer 51

Calcium channel blockers (Diltiazem, verapamil)

Hypotension and bradycardia.
Unlike B-blockers, can cause hyperglycemia and without CNS depression.

ONE PILL CAN KILL

Tx: Glucagon
IV Calcium gluconate or chloride

Question 52

Carbon monoxide

Flu-like/nonspecific symptoms (headache, weakness, fatigue, nausea, vomiting)
Causes oxyhemoglobin to bind ______ to O2. Moves oxygen curve to _______.
May or may not have _______ skin color

Dx: ABG for serum carboxyhemoglobin level by CO-oximetry
Pulse ox and PaO2 are unreliable

Removal from environment
100% oxygen by nonrebreather mask to decrease half life of CO from 4-6 hours in room air to 60-90 mins on 100% oxygen nonrebreather

Answer 52

Carbon monoxide

Flu-like/nonspecific symptoms (headache, weakness, fatigue, nausea, vomiting)
Causes oxyhemoglobin to bind more tightly to O2. Moves oxygen curve to left.
May or may not have “cherry red” skin color

Dx: ABG for serum carboxyhemoglobin level by CO-oximetry
Pulse ox and PaO2 are unreliable

Removal from environment
100% oxygen by nonrebreather mask to decrease half life of CO from 4-6 hours in room air to 60-90 mins on 100% oxygen nonrebreather

Question 53

Caustic ingestions (acidic, alkaline, oxidizing agents)
Household products: Drain cleaners, toilet bowl cleaners, laundry detergents, floor cleans, oven cleaners, swimming pool cleaners, rust removers

Acidic
- Ex______

- Taste/pain??____
- Lower risk of esophageal perforation. ______ necrosis

Alkaline agent
- Ex______
- Taste??___.

- Ingestion of small amounts can result in severe penetrating injuries by ______ necrosis

Esophageal burns/ulcerations can lead to _____

ONE PILL CAN KILL

Remove contaminated clothing

For child with no symptoms, observe for 3-4 hours and give clear liquids to see if can tolerate

iVF, analgesia. NPO until endoscopy. Do NOT induce emesis. _________ ___hours after ingestion to assess extent of injury (if too early, may not see; if too late, high risk of perforation).
Do not induce emesis. No milk, water, neutralizing substance
Chest/abdominal radiographs

Answer 53

Caustic ingestions (acidic, alkaline, oxidizing agents)
Household products: Drain cleaners, toilet bowl cleaners, laundry detergents, floor cleans, oven cleaners, swimming pool cleaners, rust removers

Acidic
- Toilet bowl cleaner, rust remover, swimming pool cleaner

- Taste bad, cause immediate pain.

- Lower risk of esophageal perforation. Coagulation necrosis (superficial)


Alkaline agent
- Bleach, ammonia, oven and drain cleaners, automatic dishwasher detergent, hair relaxers, lye, laundry detergents

- Tasteless.

- Ingestion of small amounts can result in severe penetrating injuries by liquefaction necrosis

Esophageal burns/ulcerations can lead to strictures

ONE PILL CAN KILL

Remove contaminated clothing

For child with no symptoms, observe for 3-4 hours and give clear liquids to see if can tolerate

iVF, analgesia. NPO until endoscopy. Do NOT induce emesis. Flexible endoscopy 12-24 hours after ingestion to assess extent of injury (if too early, may not see; if too late, high risk of perforation).
Do not induce emesis. No milk, water, neutralizing substance
Chest/abdominal radiographs

Question 54

Cholinergic / _________ poisoning
Inhibition of acetylcholinesterase

1) Muscarinic effects (DUMBELS): Defecation, urination, miosis, bronchorrhea/bronchospasm/bradycardia, emesis, lacrimation (tearing), and salivation.
2) Nicotinic activation leads to muscle weakness, muscle cramping/fasciculations, respiratory failure, and paralysis.
3) CNS depression: respiratory failure, seizure, coma, anxiety, confusion
________ is the most common cause of death

ONE PILL CAN KILL

ABCs
Tx: _______ or _______

Answer 54

Cholinergic / Organophosphate poisoning
Inhibition of acetylcholinesterase

1) Muscarinic effects (DUMBELS): Defecation, urination, miosis, bronchorrhea/bronchospasm/bradycardia, emesis, lacrimation (tearing), and salivation.
2) Nicotinic activation leads to muscle weakness, muscle cramping/fasciculations, respiratory failure, and paralysis.
3) CNS depression: respiratory failure, seizure, coma, anxiety, confusion
Respiratory failure is the most common cause of death

ONE PILL CAN KILL

ABCs
Atropine or pralidoxime chloride
- Atropine temporarily blocks muscarinic effects of acetylcholine
- Pralidoxime hydrolyzes the bonds with cholinesterase at nicotinic and muscarinic receptors if given before they become irreversible.

Benzo if seizure or CNS symptoms

Question 55

Clonidine (alpha 2 adrenergic agonist)

Mimic _________ toxicity.
CNS and respiratory depression, pinpoint pupils, bradycardia, hypotension, sedation/lethargy.

ONE PILL CAN KILL

Remove clonidine patch. ABCs.
Activated charcoal in severe overdoses
Monitor EKG and vital signs
- Give atropine for bradycardia that is unresponsive to stimulation

- IVF for hypotension

- Vasopressors for hypotension unresponsive to fluids


_______ for respiratory/CNS depression
• After naloxone fails, _____.

Answer 55

Clonidine (alpha 2 adrenergic agonist)

Mimic opioid toxicity.
CNS and respiratory depression, pinpoint pupils, bradycardia, hypotension, sedation/lethargy.

ONE PILL CAN KILL

Remove clonidine patch. ABCs.
Activated charcoal in severe overdoses
Monitor EKG and vital signs
- Give atropine for bradycardia that is unresponsive to stimulation

- IVF for hypotension

- Vasopressors for hypotension unresponsive to fluids


Naloxone for respiratory/CNS depression
• After naloxone fails, atropine.

Question 56

Cocaine (aka coke, blow, powder, snow white, flake, yeye)
___________

Agitation, mydriasis, diaphoresis, agitation, hallucinations, tachycardia, tachypnea, HTN, hyperthermia

Supportive. ABCs.
___ is 1st line to counteract sympathomimetic symptoms
Avoid _______ that can cause vascular construction
If refractory to benzo, tx with vasodilators _____ or _____, or_____ to counteract effects of norepinephrine

Answer 56

Cocaine (aka coke, blow, powder, snow white, flake, yeye)
Norepinephrine

Agitation, mydriasis, diaphoresis, agitation, hallucinations, tachycardia, tachypnea, HTN, hyperthermia

Supportive. ABCs.
Benzodiazepine is 1st line to counteract sympathomimetic symptoms
Avoid beta blockers that can cause vascular construction
If refractory to benzo, tx with vasodilators nitroglycerine or nitroprusside, or alpha blocker (phentolamine) to counteract alpha-stimulating effects of norepinephrine

Question 57

Cyanide (Nitroprusside)

Shock, lactic acidosis

______ given in combination with _____ or ______. Amyl nitrite (no longer rec)
ICU-setting with oxygen

Answer 57

Cyanide (Nitroprusside)

Shock, lactic acidosis

Sodium thiosulfate given in combination with sodium nitrite or hydroxocobalamin. Amyl nitrite (no longer rec)
ICU-setting with oxygen

Question 58

“Club” “Date rape” drugs

GHB (Gamma hydroxybutyrate, aka G, Liquid X) - CNS depressant approved for use in pts with narcolepsy

Flunitrazepam (Rohypnol aka Roofies, Roach) - Benzodiazepine not approved for medical use in US; importation is banned. Can cause retrograde amnesia

Answer 58

“Club” “Date rape” drugs

GHB (Gamma hydroxybutyrate, aka G, Liquid X) - CNS depressant approved for use in pts with narcolepsy

Flunitrazepam (Rohypnol aka Roofies, Roach) - Benzodiazepine not approved for medical use in US; importation is banned. Can cause retrograde amnesia

Question 59

Ethanol (Alcohol)

High osmolal gap is suspicious for ingestion of an alcohol (ethanol, methanol, ethylene glycol, isopropyl alcohol).

Ethanol, methanol and ethylene glycol ingestions cause a high anion gap metabolic acidosis, whereas isopropyl alcohol does not

Ethanol may mask toxicity caused by ingestion of other drugs, such as opioids

ABCs and IVFs

Answer 59

Ethanol (Alcohol)

High osmolal gap is suspicious for ingestion of an alcohol (ethanol, methanol, ethylene glycol, isopropyl alcohol).

Ethanol, methanol and ethylene glycol ingestions cause a high anion gap metabolic acidosis, whereas isopropyl alcohol does not

Ethanol may mask toxicity caused by ingestion of other drugs, such as opioids

ABCs and IVFs

Question 60

CHRONIC Ethanol withdrawal

6-12h: ____
12-24h: ____
24-48h: _____
48-72h: ______

Tx: ______

Answer 60

CHRONIC Ethanol withdrawal

6-12h: Minor (insomnia, tremulous, anxiety, GI upset, headache)
12-24h: Hallucinations
24-48h: Seizure
48-72h: Delirium tremens: Hallucinations (mainly visual), disorientation, tachycardia, HTN, low grade fever, agitation, diaphoresis

Tx: Benzodiazepine

Question 61

Ethylene glycol (_____)

Acute _________
Elevated anion gap metabolic acidosis
1 (0-12h): CNS, appears drunk without vomiting/drowsiness/lethargy
2 (12-36h): AKI, coma, resp distress, cardiac dysrhythmias, death
3 (24-72h): Renal failure

Typically causes a high anion gap metabolic acidosis (without lactic acidosis/ketonuria and often a high osmolal gap)
Urine will fluoresce
ONE PILL CAN KILL

__________ inhibits alcohol dehydrogenase and blocks conversion of ethylene glycol to its metabolites
Sodium bicarb for metabolic acidosis

Give thiamine and pyridoxine, which are cofactors in metabolism of ethylene glycol

Hemodialysis may be required for significant poisoning or severe renal toxicity

Answer 61

Ethylene glycol (Antifreeze)

Acute renal failure (precipitation of calcium oxalate crystals)
Elevated anion gap metabolic acidosis
1 (0-12h): CNS, appears drunk without vomiting/drowsiness/lethargy
2 (12-36h): AKI, coma, resp distress, cardiac dysrhythmias, death
3 (24-72h): Renal failure

Typically causes a high anion gap metabolic acidosis (without lactic acidosis/ketonuria and often a high osmolal gap)
Urine will fluoresce
ONE PILL CAN KILL

Fomepizole inhibits alcohol dehydrogenase and blocks conversion of ethylene glycol to its metabolites
Sodium bicarb for metabolic acidosis

Give thiamine and pyridoxine, which are cofactors in metabolism of ethylene glycol

Hemodialysis may be required for significant poisoning or severe renal toxicity

Question 62

Hydrocarbon
Mineral, motor, baby, suntan oils (low toxicity). Mineral spirits, lamp oil, gasoline, furniture polish, kerosine, lighter fluid (high aspiration risk).

Highly toxic hydrocarbons are CHAMP
- Camphor

- Halogenated (trichloroethane, trichloroethylene)

- Aromatic (benzene, toluene, xylene)
-
Metal (arsenic, mercury) in hydrocarbon base
-
Pesticide (organophosphate) in hydrocarbon base

Most frequent toxicity is aspiration pneumonitis
Arrhythmias and CNS depression can occur

ONE PILL CAN KILL

External decontamination
Asymptomatic children can be observed for 6-8h. If remain asx, CXR normal, dc

In presence of concerning symptoms or CXR findings, supportive care with oxygen and airway protection.

______ occurs in severe cases.
Tx of lung injury is mostly supportive. Give ___

Answer 62

Hydrocarbon
Mineral, motor, baby, suntan oils (low toxicity). Mineral spirits, lamp oil, gasoline, furniture polish, kerosine, lighter fluid (high aspiration risk).

Highly toxic hydrocarbons are CHAMP
- Camphor

- ​Halogenated (trichloroethane, trichloroethylene)

- Aromatic (benzene, toluene, xylene)
-
​Metal (arsenic, mercury) in hydrocarbon base
-
​Pesticide (organophosphate) in hydrocarbon base

Most frequent toxicity is aspiration pneumonitis
Arrhythmias and CNS depression can occur

ONE PILL CAN KILL

External decontamination
Asymptomatic children can be observed for 6-8h. If remain asx, CXR normal, dc

In presence of concerning symptoms or CXR findings, supportive care with oxygen and airway protection.

ARDS occurs in severe cases.
Tx of lung injury is mostly supportive. Give PEEP

Question 63

Imidazolines (_____ agonist)

Found in ________

Hypotension, bradycardia, miosis, hypothermia, hyporeflexia, CNS sx, resp depression

ONE PILL CAN KILL

Activated charcoal is most effective for GI decontamination when administered within 2 hours

Children who are asymptomatic 6 hours after ingestion may be discharged from the hospital if continued close supervision for 24 hours

Answer 63

Imidazolines (alpha 2 adrenergic agonist)

Found in OTC medications for topical ophthalmic, nasal decongestions / meds for common cold or seasonal allergies

Hypotension, bradycardia, miosis, hypothermia, hyporeflexia, CNS sx, resp depression

ONE PILL CAN KILL

Activated charcoal is most effective for GI decontamination when administered within 2 hours

Children who are asymptomatic 6 hours after ingestion may be discharged from the hospital if continued close supervision for 24 hours

Question 64

Inhalants
“Gluey” “Huff” “Poppers’ “whippets” (glue, toluene, nitrous oxide, amyl nitrite, and spray paints)

Effects last 15-45 mins

Acute, mimics _______ ingestion

“Glue-sniffer’s rash” - perioral dermatitis

“Sudden sniffing death syndrome” - ____

Combination of acute _____ changes and a _____ is highly concerning for overdose

Tx?___

Answer 64

Inhalants
“Gluey” “Huff” “Poppers’ “whippets” (glue, toluene, nitrous oxide, amyl nitrite, and spray paints)

Effects last 15-45 mins

Acute, mimics alcohol ingestion (ataxia, slurred speech)

“Glue-sniffer’s rash” - perioral dermatitis

“Sudden sniffing death syndrome” - Fetal cardiac arrhythmia due to desensitization of myocardial cells to epinephrine; EKG with ventricular tachycardia

Combination of acute CNS changes and a ventricular arrhythmia is highly concerning for overdose

ABCs. Inhalants are rapidly eliminated.

Question 65

Iron

<20mg/kg - mild/asymptomatic.
20-60mg/kg- moderate toxicity; variable symptoms, with some patients remaining asymptomatic and others showing signs of serious toxicity
>60mg/kg- potentially severe

1 (0-6h) \_\_\_\_
2 (6-24h)\_\_\_
3 (6-72h)\_\_\_\_
4 (12-96h): \_\_\_\_
5 (2-8w): \_\_\_\_\_

Serum Iron level at 4-6 hours after ingestion

• Nontoxic level is ___ ug/dL produces serious toxicity, >___mcg/dL significant mortality
• And radiograph may confirm ingestion

______ for moderate-severe symptoms, a significant number of radiopaque pills on radiography, or peak serum iron concentration >____ ug/dL (90umol/L). It is a chelating agent that attaches to Fe3+ ferric iron in blood to form water soluble ferrioxamine, which is renally excreted and changes urine to _____

Controversial. Whole bowel irrigation controversial if large number of pills. Do not use gastric lavage, ipecac, activated charcoal (does not bind iron), oral bicarbonate, magnesium hydroxide, and oral deferoxamine.

Answer 65

Iron

<20mg/kg - mild/asymptomatic.
20-60mg/kg- moderate toxicity; variable symptoms, with some patients remaining asymptomatic and others showing signs of serious toxicity
>60mg/kg- potentially severe

1 (0-6h, GI stage): Corrosion to GI (abd pain, nausea, vomiting, diarrhea)
2 (6-24h, stability): Relative stability/latent. Apparent recovery, asx
3 (6-72h, systemic toxicity): Shock and metabolic acidosis.
- Coma, hypovolemia shock, severe metabolic acidosis, hepatic failure
4 (12-96h): Hepatotoxicity
5 (2-8w): GI/pyloric scarring, bowel obstruction

Serum Iron level at 4-6 hours after ingestion

• Nontoxic level is <350 ug/dl; 350-500 ug/dL produces mild-to-moderate symptoms; level >500 ug/dL produces serious toxicity, >1000mcg/dL significant mortality
• And radiograph may confirm ingestion

IV Deferoxamine for moderate-severe symptoms, a significant number of radiopaque pills on radiography, or peak serum iron concentration >500 ug/dL (90umol/L). It is a chelating agent that attaches to Fe3+ ferric iron in blood to form water soluble ferrioxamine, which is renally excreted and changes urine to dark color “vine rose”

Controversial. Whole bowel irrigation controversial if large number of pills. Do not use gastric lavage, ipecac, activated charcoal (does not bind iron), oral bicarbonate, magnesium hydroxide, and oral deferoxamine.

Question 66

Isopropyl alcohol
______ alcohol

CNS depression
Severe GI irritation can lead to hemorrhagic gastritis

Ketosis and osmolar gap without acidosis

ONE PILL CAN KILL

Supportive care

Answer 66

Isopropyl alcohol
Rubbing alcohol

CNS depression
Severe GI irritation can lead to hemorrhagic gastritis

Ketosis and osmolar gap without acidosis

ONE PILL CAN KILL

Supportive care

Question 67

Lead

Typically asymptomatic
Cognitive impairment and behavioral problems.

Elevated if >____ug/dL

Basophilic stippling peripheral smear

Identify and eliminate sources of exposure
__-___ ug/dL: Reduce exposure, nutrition counseling, and repeat venous blood level in 1 mo, then retest q3mo
>___ ug/dL: Chelation therapy
- Moderate __-__: ________
- Severe >__or __: ________

Tx does not reverse neurocognitive defects

Answer 67

Lead

Typically asymptomatic
Cognitive impairment and behavioral problems.

Elevated if >5ug/dL

Basophilic stippling peripheral smear

Identify and eliminate sources of exposure
5-45 ug/dL: Reduce exposure, nutrition counseling, and repeat venous blood level in 1 mo, then retest q3mo
>45 ug/dL: Chelation therapy
- Moderate 45-69: Oral DMSA (succimer; dimercaptosuccinic acid)

- Severe >70 or encephalopathy: Medical emergency. Chelation with Dimercaprol plus EDTA (calcium disodium edetate)


Tx does not reverse neurocognitive defects

Question 68

LSD

Somatic sx (dizziness, dilated pupils, flushing) followed by hallucinations..
Hallucinogen persisting perception disorder (“flashbacks”)
Hallucinogens act at ____ receptors and risk for _____ toxicity

Tx?_____

Answer 68

LSD

Hallucinations.
Hallucinogen persisting perception disorder (“flashbacks”)
Hallucinogens act at serotonin receptors and risk for serotonin toxicity

Supportive. Self-limited. May use benzo

Question 69

Marijuana

Tachy, HTN, hunger, red conjunctiva, decreased concentration, increased anxiety, impairment of short term memory, hallucinogenic, ataxia, nystagmus

Cannabinoid hyperemesis syndrome

Supportive. Sometimes Benzo

Answer 69

Marijuana

Tachy, HTN, hunger, red conjunctiva, decreased concentration, increased anxiety, impairment of short term memory, hallucinogenic, ataxia, nystagmus

Cannabinoid hyperemesis syndrome

Supportive. Sometimes Benzo

Question 70

Marijuana withdrawal:

Dx: Clinical based on 3 of 7 symptoms
- Anxiety

- Restlessness

- Irritability/aggression

- Insomnia

- Decreased appetite/weight loss

- Depression

- Somatic complaints (including tremors, sweating, fever, chills, and abdominal pain)

Answer 70

Marijuana withdrawal:

Dx: Clinical based on 3 of 7 symptoms
- Anxiety

- Restlessness

- Irritability/aggression

- Insomnia

- Decreased appetite/weight loss

- Depression

- Somatic complaints (including tremors, sweating, fever, chills, and abdominal pain)

Question 71

Methanol
Windshield wiper fluid, perfumes, cooking fuels, printing solutions

______ is main toxic metabolite

Triad: _____ disturbances, abdominal pain, anion gap metabolic acidosis (without lactic acidosis or ketonuria)

ONE PILL CAN KILL

ABCs
_____ a competitive antagonist of alcohol dehydrogenase

Answer 71

Methanol
Windshield wiper fluid, perfumes, cooking fuels, printing solutions

Formic acid is main toxic metabolite

Triad: Visual disturbances (optic nerve damage), abdominal pain, anion gap metabolic acidosis (without lactic acidosis or ketonuria)

ONE PILL CAN KILL

ABCs
Fomepizole a competitive antagonist of alcohol dehydrogenase

Question 72

Methemoglobinemia

Ferrous Hgb is converted to ferric form so oxygen binds poorly

Chocolate brown blood
Saturation gap between pulse ox and ABG
Dx: CO-oximetry

Removal of agent
Asx/ Methemoglobin <20%:_______
100% oxygen
Symptomatic: Use of _____ (CI with ______)
Severe: Blood/exchange transfusion, hyperbaric oxygen
Chronic hereditary is best tx with ascorbic acid

Answer 72

Methemoglobinemia

Ferrous Hgb is converted to ferric form so oxygen binds poorly

Chocolate brown blood
Saturation gap between pulse ox and ABG
Dx: CO-oximetry

Removal of agent
Asx/ Methemoglobin <20%: No therapy
100% oxygen
Symptomatic: Use of IV methylene blue (CI with G6PD deficiency)
Severe: Blood/exchange transfusion, hyperbaric oxygen
Chronic hereditary is best tx with ascorbic acid

Question 73

NSAIDs

Asymptomatic. Some GI upset, renal failure

Supportive care. Observe for 4-6 hours.

Answer 73

NSAIDs

Asymptomatic. Some GI upset, renal failure

Supportive care. Observe for 4-6 hours.

Question 74

Opioids

Triad: Respiratory depression, CNS depression, miosis

ABCs.
________ (repeat doses often necessary as half life (30 mins) is shorter than most opiates)

________ bc of risk of Torsades de Pointes and QTc prolongation

Answer 74

Opioids

Triad: Respiratory depression, CNS depression, miosis

ABCs.
Naloxone (repeat doses often necessary as half life (30 mins) is shorter than most opiates)
• Naloxone is likely to precipitate withdrawal syndrome (eg agitation, anxiety, nausea, vomiting) if the pt is opioid dependent


Magnesium bc of risk of Torsades de Pointes and QTc prolongation

Question 75

Opioid withdrawal

Yawning, followed by lacrimation, mydriasis, insomnia, restlessness, diarrhea, emesis, tremors, HTN

ONE PILL CAN KILL

Buprenorphine, naltrexone, methadone

Answer 75

Opioid withdrawal

Yawning, followed by lacrimation, mydriasis, insomnia, restlessness, diarrhea, emesis, tremors, HTN

ONE PILL CAN KILL

Buprenorphine, naltrexone, methadone

Question 76

PCP

_________ is pathognomonic. Rhabdomyolysis (elevated CK) leads to AKI. Agitation, psychosis, HTN, tachypnea, tachycardia

Supportive

Benzo for severe symptoms

Answer 76

PCP

Vertical and horizontal nystagmus is pathognomonic. Rhabdomyolysis (elevated CK) leads to AKI. Agitation, psychosis, HTN, tachypnea, tachycardia

Supportive

Benzo for severe symptoms

Question 77

Salicylates
(Aspirin, oil of wintergreen, methyl salicylate, bismuth subsalicylate)

Tinnitus, GI symptoms (nausea, vomiting, GI hemorrhage), CNS symptoms (confusion, seizures, coma), Metabolic acidosis and respiratory alkalosis is classic, hypoglycemia

Reye syndrome

ABCs. Within 1 hour, activated charcoal
Salicylate level q1-2h
IVF (careful, avoid pulm edema) and electrolytes

_______ to alkalinize urine to pH >7.5 (while avoiding serum alkalosis arterial pH>7.55), which traps salicylates in blood (away from brain tissue) and renal tubules (enhance elimination)

Answer 77

Salicylates
(Aspirin, oil of wintergreen, methyl salicylate, bismuth subsalicylate)

Tinnitus, GI symptoms (nausea, vomiting, GI hemorrhage), CNS symptoms (confusion, seizures, coma), Metabolic acidosis and respiratory alkalosis is classic, hypoglycemia

Reye syndrome

ABCs. Within 1 hour, activated charcoal
Salicylate level q1-2h
IVF (careful, avoid pulm edema) and electrolytes

Sodium bicarbonate to alkalinize urine to pH >7.5 (while avoiding serum alkalosis arterial pH>7.55), which traps salicylates in blood (away from brain tissue) and renal tubules (enhance elimination)

Question 78

TCAs (Imipramine, Amitriptyline, Desipramine, Nortriptyline)
1. Anticholinergic

2. Alpha blockers

3. Block sodium channels in cardiovascular system

4. Neurotoxic (inhibit NE, serotonin, dopamine in CNS)

CCCA:
____, _____, _____, ______

Any child with neurologic and cardiac abnormalities (seizures and arrhythmia) in the setting of metabolic acidosis.
Think TCA overdose when see somnolence, hypotension, seizures, and anticholinergic signs.

ONE PILL CAN KILL

ABCs. IVFs for hypotension
Activated charcoal if significant overdose
EKG
- QRS >100 msec / 0.1 sec indicates potential potential cardiac toxicity
- Rightward deflection of terminal 40msec of QRS
__________ is preferred for QRS widening or treating cardiac arrhythmias. It corrects acidosis and decreases binding of drug to myocardium, protecting cardiac myocardial cells. ______ contraindicated.

Treat seizures with _____ and ______; avoid ____
- CI: ______ is CI in tx of TCA bc lowers seizure threshold and worsens ventricular conduction abnormalities
- _____ should be avoided bc may provoke seizures

Answer 78

TCAs (Imipramine, Amitriptyline, Desipramine, Nortriptyline)
1. Anticholinergic

2. Alpha blockers

3. Block sodium channels in cardiovascular system

4. Neurotoxic (inhibit NE, serotonin, dopamine in CNS)

CCCA:
Coma, Convulsions, Cardiac dysrhythmias (widened QRS, prolonged QTc), Acidosis/Anticholinergic

Any child with neurologic and cardiac abnormalities (seizures and arrhythmia) in the setting of metabolic acidosis.
Think TCA overdose when see somnolence, hypotension, seizures, and anticholinergic signs.

ONE PILL CAN KILL

ABCs. IVFs for hypotension
Activated charcoal if significant overdose
EKG
- QRS >100 msec / 0.1 sec indicates potential potential cardiac toxicity
- Rightward deflection of terminal 40msec of QRS
Sodium bicarbonate is preferred for QRS widening or treating cardiac arrhythmias. It corrects acidosis and decreases binding of drug to myocardium, protecting cardiac myocardial cells. Procainamide contraindicated.

Treat seizures with benzodiapines and phenobarbital; avoid phenytoin
- CI: Physostigmine is CI in tx of TCA bc lowers seizure threshold and worsens ventricular conduction abnormalities
- Flumazenil should be avoided bc may provoke seizures

Question 79

Warfarin

Vitamin K

Answer 79

Warfarin

Vitamin K

Question 80

Serotonin Syndrome

• SSRIs, MAOIs, SNRIs, TCAs, and hallucinogens, ecstasy MDMA. Linezolid
• ____ post-exposure
• Pt:
  
  • Muscle rigidity
  • ______ is the most specific finding (helps distinguish from mimics, including NMS and malignant hyperthermia)
  • _____reflexia (contrast to neuroleptic malignant syndrome)
  • If pt as bruxism, ______ is likely to be one of the culprits.
• Tx: _______

Answer 80

Serotonin Syndrome

• SSRIs, MAOIs, SNRIs, TCAs, and hallucinogens, ecstasy MDMA. Linezolid
• Comes on quickly (hours post-exposure)
• Pt:
  
  • Muscle rigidity
  • Myoclonus is the most specific finding (helps distinguish from mimics, including NMS and malignant hyperthermia)
  • Hyperreflexia (contrast to neuroleptic malignant syndrome, which has hyporeflexia)
  • If pt as bruxism, ecstasy is likely to be one of the culprits.
• Tx: Supportive

Question 81

Neuroleptic Malignant Syndrome

• Antipsychotics: Haloperidol, fluphenazine, clozapine, risperidone
• Antiemetics: metoclopramide
• ____ post-exposure
• Pt:
  
  • Hyperthermia, (diffuse) muscle rigidity, confusion, autonomic instability
  • _______reflexia
• Tx: Supportive
  
  • _______, bromocriptine, and amantadine are commonly used by controversial as data is scant and conflicting

Answer 81

Neuroleptic Malignant Syndrome

• Antipsychotics: Haloperidol, fluphenazine, clozapine, risperidone
• Antiemetics: metoclopramide
• Slow onset (days)
• Pt:
  
  • Hyperthermia, (diffuse) muscle rigidity, confusion, autonomic instability
  • Hyporeflexia
• Tx: Supportive
  
  • Dantrolene, bromocriptine, and amantadine are commonly used by controversial as data is scant and conflicting

Question 82

Ketamine

- Airway protected. Good for low ___ and for_____. Contraindicated with ______

Answer 82

Ketamine
- Airway protected. Good for low BP (causes HTN) and for asthma (is a bronchodilator). Contraindicated with increased ICP.

Question 83

Propofol

• Airway protected. Safe, quick on, quick off
• Absolute CI: ____, ___, or ____

Answer 83

Propofol

• Airway protected. Safe, quick on, quick off
• Absolute CI: Egg allergy, soy allergy, or porphyria

Question 84

Dexmedetomidine (Precedex)

• Can cause ______. _____ respiratory depression
• Absolute CI: ______

Answer 84

Dexmedetomidine (Precedex)

• Can cause bradycardia. NO respiratory depression
• Absolute CI: Digoxin or other meds slowing conduction to the AV node, cardiac conduction abnormalities, and other cardiac dysfunction

Question 85

Etomidate (Amidate)

• ______ airway. _____ ICP. ____ BP. Provides both analgesia and sedation.
• Absolute CI: ________

Answer 85

Etomidate (Amidate)

• Decreased airway. Decreases ICP. Provides both analgesia and sedation. Contraindicated in adrenal insufficiency or septic shock; can’t use in neonatal sepsis bc adrenal suppressor. Does not decrease BP.
• Absolute CI: Adrenal insufficiency

Question 86

Dextromethorphan / Robitussin should not be used <6yo; can cause sudden cardiac death

• Commonly found in OTC cough syrups
• When taken in excess, it can cause euphoria, _____, a feeling of dissociation, delirium, tachycardia, ____, mydriasis (or miosis), diaphoresis, ____ speech, ____reflexia
• Tx of overdose is supportive.

Answer 86

Dextromethorphan / Robitussin should not be used <6yo; can cause sudden cardiac death

• Commonly found in OTC cough syrups
• When taken in excess, it can cause euphoria, visual hallucinations, a feeling of dissociation, delirium, tachycardia, nystagmus, mydriasis (or miosis), diaphoresis, slurred speech, hyperreflexia
• Tx of overdose is supportive.

Question 87

Endotracheal intubation for pediatrics

• Size (mm)
  
  • Uncuffed: tube = __ + __
  • Cuffed: tube = __ + __
• Depth:
  
  • Child <1 year: Depth of intubation cm = __ + ___
  • Child >1 year: Depth of intubation cm = __ + ___

Answer 87

Endotracheal intubation for pediatrics

• Size (mm)
  
  • Uncuffed: tube = (age/4) + 4
  • Cuffed: tube = (age/4) + 3.5
• Depth:
  
  • Child <1 year: Depth of intubation cm = weight/2 + 8
  • Child >1 year: Depth of intubation cm = age/2 + 13

Question 88

Malignant Hyperthermia

• ____ mutation in the _____ which leads to prolonged opening and excess cytosolic _____, and thus prolonged muscle contractions, then lactic acidosis, hypoxia, hyperthermia.
• Triggers: Volatile inhalational anesthetics (halothane, isoflurane, desflurane), depolarizing neuromuscular blocking agent _____
• _____ post-exposure
• PT: ____reflexia.
• Management:
  
  • Potentially causative agents should be discontinued
  • _____, a ryanodine receptor agonist, which prevents release of calcium from the sarcoplasmic reticulum, should be administered immediately.
  • Supportive care for hypercarbia, hypoxia, hyperthermia, and acidosis may include ventilator strategies, temperature control, and sodium bicarcarbonate as needed

Answer 88

Malignant Hyperthermia

• AD mutation in the ryanodine receptor, which leads to prolonged opening and excess cytosolic calcium, and thus prolonged muscle contractions, then lactic acidosis, hypoxia, hyperthermia.
• Triggers: Volatile inhalational anesthetics (halothane, isoflurane, desflurane), depolarizing neuromuscular blocking agent succinylcholine
• HOURS post-exposure
• PT: Hyporeflexia.
• Management:
  
  • Potentially causative agents should be discontinued
  • Dantrolene, a ryanodine receptor agonist, which prevents release of calcium from the sarcoplasmic reticulum, should be administered immediately.
  • Supportive care for hypercarbia, hypoxia, hyperthermia, and acidosis may include ventilator strategies, temperature control, and sodium bicarcarbonate as needed

Question 89

Children undergoing sedation for scheduled elective procedures observe the following NPO fasting guidelines

• ___ hours after receiving clear liquids
• ___ hours after breastfeeding
• ___ hours after ingesting non-fatty solid foods (eg toast or bananas), formula, or milk other than human milk
• ___ hours after full meals

Answer 89

Children undergoing sedation for scheduled elective procedures observe the following NPO fasting guidelines

• 2 hours after receiving clear liquids
• 4 hours after breastfeeding
• 6 hours after ingesting non-fatty solid foods (eg toast or bananas), formula, or milk other than human milk
• 8 hours after full meals

Question 90

A general pediatrician must understand 2 important concepts:

• 1. Most sedation medications have a bell-shaped dose response: 80% of patients respond as expected, whereas 10% have a very sensitive response and 10% are more resistant than expected
• 2. If the recommended max total dose is given or exceeded, the pt has a HIGH risk of progressing to deep sedation or general anesthesia.

Answer 90

A general pediatrician must understand 2 important concepts:

• 1. Most sedation medications have a bell-shaped dose response: 80% of patients respond as expected, whereas 10% have a very sensitive response and 10% are more resistant than expected
• 2. If the recommended max total dose is given or exceeded, the pt has a HIGH risk of progressing to deep sedation or general anesthesia.