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My Step 2 CK > Emergency Medicine > Flashcards

Emergency Medicine Flashcards

1
Q

What is the treatment for a pt at home who reports recent toxic ingestion but not at the hospital?

A

Ipecac (induces vomiting; beneficial w/in 1-2 hours of ingestion)

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2
Q

What is the initial treatment for choice for a pt arriving at the hospital after toxic ingestion?

A

Charcoal (blocks absorption and promotes excretion; can be used at any time)

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3
Q

What is the cocktail of medication given to a pt who presents to the emergency department with altered mental status?

A

naloxone, dextrose and thiamine

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4
Q

What is the treatment of choice for toxic-related seizures?

A

benzos

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5
Q

A pt presents with nausea, vomiting, and elevated liver enzymes after ingestion of pills most likely suffers from …

A 
Acetaminophen intoxicity
(>7 grams)
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6
Q

What is the treatment for acetominophen toxicity?

A

N-acetyl cysteine (NAC) and charcoal

useful for first 48 hours

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7
Q

What are characteristic findings in a pt with methanol intoxication (paint thinner, windshield washer fluid)? (3)

A
  1. visual disturbances (snow field blindness, nystagmus)
  2. metabolic acidosis with anion gap
  3. elevated osmolar gap (before metabolized)

(due to formic acid metabolite)

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8
Q

What are characteristic findings in a pt with ethylene glycol intoxication (antifreeze)? (5)

A
  1. oxalate crystals
  2. renal failure (elevated BUN and creatinine)
  3. urine fluorescence under wood’s lamp
  4. metabolic acidosis with anion gap
  5. elevated osmolar gap (before metabolized)

(due to oxalic acid metabolite)

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9
Q

A pt presenting with altered mental status, pulmonary symptoms and cardiac symptoms after exposure to smoke inhalation or fire with metabolic acidosis and normal pO2 most likely suffers from …

A

Carbon monoxide poisoning

family w/ flu symptoms

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10
Q

What is the treatment for carbon monoxide poisoning?

A
  1. removal from source

2. 100% oxygen or hyperbaric oxygen

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11
Q

What is the treatment for acid and alkali causatic ingestions?

A
  1. wash out mouth with cold water
  2. irrigate ocular exposure with saline/ water (until normal pH)
    (avoid inducing emesis or neutralizing acid or base)
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12
Q

What is the treatment for digoxin toxicity?

A
  1. charcoal
  2. digiband (if arrhthymias, K>5.5, digoxin > 10)
  3. correct potassium
  4. treat arrhythmia (lidocaine, phenytoin for V tach; Mg for torsades; atropine, pacer for bradycardia)
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13
Q

What is the treatment for opiate intoxication?

A

naloxone (shorter half life than opiate so may need repeated doses)

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14
Q

A pt presents with pupillary constriction and respiratory depression along with bradycardia and hypotension most likely suffers from …

A

opiate toxicity

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15
Q

What toxins can cause miosis (pupillary constriction)?

A
  1. clonidine
  2. barbituates
  3. opiates
  4. cholinergics
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16
Q

What toxins can cause mydriasis (pupillary dilation)?

A
  1. sympathomimetics (cocain, amphetamine)

2. anticholinergics

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17
Q

What toxins causes dry skin (anhidriosis)?

A

anticholinergics

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18
Q

A pt presents with altered mental status with pinpoint pupils, respiratory depression, and hypotension with associated hx of cancer or IV drug use most likely suffers from intoxication with …

A

opiates

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19
Q

A pt presents violent, tachycardiac, hypertensive, dilated pupils, diaphoretic, and acting crazy most likely suffers from intoxication with …

A

Sympathomimetics

amphetamine, cocaine, PCP

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20
Q

A pt presents with farmer dusting crops or depressed pt who drank insecticide presenting with miosis, salivation, urination, defecation, lacrimation, bradycardia and bronchospasm (wheezing) most likely suffers from intoxication from …

A

Cholinergics

die from respirtory depression due to muscle fasciculations and weakness

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21
Q

What is the medical treatment for cholinergic intoxication?

A
  1. Atropine (inhibitor of ACh receptors)
  2. pralidoxime (2-PAM restores cholinesterase activity)

(doctor wear protective clothing and remove pt clothes b/c absorbed thru skin)

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22
Q

What are tests that can confirm the diagnosis of cholinergic toxication?

A

RBC or plasma cholinesterase level

takes two weeks to return

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23
Q

A pt presents with tachycardia, altered mental status (mad as a hatter), anhidriosis (dry skin; dry as bone), fever (hot as hare), mydriasis (blind as a bat), flushed (red as a beet), and constipated with urinary retention (full as a flask) most likely suffers from intoxication from …

A

Anticholingerics

TCAs

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24
Q

What toxins can causes wet skin (diaphoresis)?

A
  1. cholinergics

2. sympathomimetics (amphetamine, cocaine, PCP)

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25
Q

What toxins can cause blisters?

A
  1. barbituates

2. carbon monoxide poisoning

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26
Q

What treatment can be used to prevent absorption of ingested pills within 1 hour of ingestion?

A 
Gastric Lavage
(must intubate first if altered mental status; can't do after 1 hour)
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27
Q

What are contraindications to gastric lavage?

A
  1. acid and alkaline ingestions
  2. past 1 hour of ingestion
  3. hydrocarbon ingestion (gasoline)
  4. altered pt who is not intubated
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28
Q

What drugs are contraindicated in cocaine toxicity?

A

beta blockers (b/c leads to unopposed alpha stimulation)

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29
Q

When do you use whole bowel irrigation with golytely?

A

pills located beyond stomach and things not absorbed rapidly (packets of drugs being smuggled, sustained release meds, iron, lithium)

(things that show up on X-ray)

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30
Q

What pills will show up on X-ray?

A

CHIPES

chloral hydrate, heavy metals, iron, packers, enteric coated meds, sustained release

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31
Q

What 2 drugs that you can aid elimination with forced alkaline diuresis (bicarbonate)?

A
  1. aspirin

2. phenobarbital

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32
Q

What substances/ drugs that may require hemodialysis for removal in overdose?
(ISTUMBLE)

A
  1. isopropanol
  2. salicylates
  3. theophylline
  4. uremia
  5. methanol
  6. barbituates
  7. lithium
  8. ethylene glycol
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33
Q

What is the treatment for cocaine intoxication associated agitation?

A

benzo

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34
Q

What are treatment options for cocaine intoxication associated hypertension?

A
  1. labetalol (combined alpha/beta agent)
  2. phentolamine (alpha blockers)
  3. nitroprusside
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35
Q

What is a complication of flumazenil use in a benzo intoxication?

A

seizures (acute withdrawal symptom)

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36
Q

What lab test is used to determine whether a pt with acetominophen intoxication requires liver transplant?

A

PT (if normal, liver will recover)

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37
Q

What is the treatment for barbituate intoxication (can lead to respiratory/ CNS depression)?

A

bicarbonate (to increase urinary excretion of phenobarbital)

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38
Q

What is the treatment for methanol or ethylene glycol?

A
  1. ethanol
  2. fomepizole

(block alcohol dehydrogenase to prevent toxic metabolite production)

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39
Q

What vitamin can be used to help with methanol intoxication?

A

Folate

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40
Q

What are characteristic findings in a pt with isopropyl intoxication? (5)

A
  1. nystagamus
  2. GI bleeding
  3. renal & liver dysfunction
  4. anemia
  5. CNS deficits (coma, hypoventilation)
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41
Q

What vitamin cofactors can be used to help with ethylene glycol intoxication?

A
  1. thiamine
  2. pyridoxine (vitamine B6)
  3. ketonemia & ketonuria
  4. elevated osmolar gap
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42
Q

A pt presents with abdominal pain, microcytic anemia, neuro symptoms (headache, memory loss, seizures) most likely suffers from ….. poisoning

A

Lead

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43
Q

What is the diagnostic tests for lead poisoning?

A
  1. blood lead levels (> 10ug/dL)

2. lead lines (density at metaphyseal plate of long bones in kids signifying long-term exposure)

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44
Q

What is treatment for lead poisoning?

A
  1. Charcoal (if acute)

2. chelation (EDTA, dimercaprol (BAL), penicillamine, succimer)

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45
Q

What is the treatment for mercury poisoning?

A
  1. remove from source

2. chelation w/ succimer or dimercaprol (BAL)

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46
Q

A pt working in an industrial manufacturing plant presents with interstitial penumonitis, GI distress, and erethism (tremors, excitability, memory loss, delirium, insomnia) most likely suffers from …. poisoning

A

Mercury

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47
Q

What is the next best step in a pregnant women with GI distress and a carbon monoxide level >15%?

A

treat with oxygen (b/c fetal hemoglobin binds more tightly to CO then maternal hemoglobin)

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48
Q

A pt presents with GI distress, tinnitus, hyperventilation, CNS toxicity, and metabolic acidosis with elevated anion gap most likely suffers from …. intoxication

A

Salicylates (aspirin)

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49
Q

What is the most accurate test for salicylate intoxication?

A

aspirin level

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50
Q

What is the treatment for salicylate intoxication?

A
  1. gastric lavage (if w/in 1 hour)
  2. charcoal
  3. bicarbonate (alkalization of urine)
  4. aggressive fluid resuscitation (increase urine output)
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51
Q

What salicylate level is an indication for dialysis?

A

> 100 mg/dl

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52
Q

What diagnostic tool can be used to assess the extent of injury after acid or alkali caustic ingestion?

A

endoscopy

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53
Q

A pt presents with GI distress, hyperkalemia, blurred vision, color vision abnormality and arrhythmia most likely suffers from …. intoxication

A

digoxin

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54
Q

A pt presents with dry mouth, tachycardia, dilated pupils, flushed skin, CNS effects and dysrhythmia with QRS widening most likely suffers from …. intoxication

A

Tricyclic Antidepressants (TCA)

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55
Q

What are common complications from cocaine abuse?

A
  1. hemorrhagic stroke
  2. myocardial infarction
  3. subarachnoid hemorrhage
  4. arrhythmia
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56
Q

What is the most accurate test for TCA intoxication?

A

serum drug level

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57
Q

What diagnostic test is important to determine the severity of the TCA intoxication?

A

EKG (detect dysrhythmia)

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58
Q

A pt presents unconscious with weak pulse, respiratory depression, nonreactive pupils and absent EEG activity most likely suffers from …. intoxication

A

barbituate

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59
Q

What is the treatment for tricyclic antidepressant intoxication?

A
  1. charcoal (acutely b/c slowed gastric empyting due to TCA)

2. Bicarbonate (protect heart if dysrhythmia)

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60
Q

What is the treatment for severe hallucinogen intoxication?

A

Benzos

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61
Q

What is treatment for anticholinergic intoxication associated seizures?

A

benzos

62
Q

What is treatment for anticholinergic intoxication prolonged QRS and QT intervals?

A

Sodium Bicarbonate (stabilize cardiac membrane)

63
Q

What is the treatment for TCA associated dysrhythymia?

A

Sodium Bicarbonate (stabilize cardiac membrane)

64
Q

An alcoholic pt presents with paranoid psychosis and auditory/ visual/ tactile hallucinations 12-24 hours after last drink most likely suffers from …

A

Alcoholic hallucinosis

65
Q

What is the treatment for alcoholic hallucinosis?

A

benzos and haldoperidol (no risk of seizure)

66
Q

An alcoholic pt presents with mental confusion, autonomic hyperactitiy, visual hallucinations, agiataion and diaphoresis 48-72 hours after last drink most likely suffers from …

A

Delirium tremens

tx: benzos

67
Q

What is the best initial way to open airway in suspected neck injury?

A

Jaw thrust maneuver

68
Q

An alcoholic pt develops confusion, ataxia and nystagmus (ophthalmoplegia) most likely suffers from …. due to …. deficiency

A

Wernicke encephalopathy; thiamine

69
Q

An alcoholic pt develops amnesia and confabulation most likely suffers from …. due to … deficiency

A

Korsakoff psychosis; thiamine

70
Q

What is treatment for Wernicke encephalopathy and Korsakoff psychosis?

A

IV thiamine

71
Q

What is the initial management algorithm of any pt who seems to have become unresponsive?

A
  1. assess responsiveness of pt
  2. call for help
  3. ABCs (airway, breathing, circulation)
  4. start CPR (30 compressions to 2 ventilations)
72
Q

What are ways to open and maintain an open airway? (in sequence)

A
  1. head tilt-chin lift maneuver or jaw thrust
  2. remove obstructing objects
  3. oral airway (non-awake pt) or nasopharyngeal airway (awake & sleep pt)
  4. endotracheal tube (prevents aspiration, requires sedation for placment)
  5. cricothyroidotomy (can’t get other airway)
73
Q

When is cricothyroidotomy contraindicated?

A

children

74
Q

What is the initial step in management for circulation problems (bleeding, shock, delayed cap refill)?

A
  1. give IV fluid (0.9% normal saline or lactate ringers)

2. type and cross for packed RBC

75
Q

What is the initial step in management for suspected neck injury?

A

place C-collar on and place on backboard

maintain proper alignment

76
Q

What is electrical defibrillation?

A

nonsynchronized delivery of shock to heart

77
Q

What is electrical cardioversion?

A

synchronized delivery of shock with the QRS complex

78
Q

What cardiac rhythms are treated with electrical defibrillation?

A
  1. ventricular fibrillation

2. pulseless ventricular tachycardia

79
Q

What is the most common arrest rhythm?

A

ventricular fibrillation

80
Q

What is treatment for a pt who is not following commands or showing purposeful movements after resuscitation (CPR and AED)?

A

hypothermia protocol (core temp of 90-93 within 6 hours and maintain for 12-24)

81
Q

What is the sequence of events for a pt found to be in asystole (absence of electrical activity) or pulseless electrical activity?

A
  1. CPR
  2. obtain IV access
  3. give epinephrine 1 mq every 3-5 minutes
    (can replace 1st or 2nd dose with vasopressin 40 units)
82
Q

What is the sequence of events for pulseless shockable rhythms (V-fib, pulseless V-tach, torsades de pointes)?

A
  1. defibrillate
  2. CPR for 2 minutes
  3. check rhythm
  4. shock (if rhythm persists)
  5. CPR for 2 minutes and give meds (epinephrine or vasopressin)
    (Magnesium for torsades; can use amiodaron or lidocaine)
83
Q

What is the treatment for ventricular tachycardiac with pulse but hemodynamically unstable (hypotensive, chest pain, altered mental status, CHF)?

A

synchronized cardioversion (after sedation with midazolam)

84
Q

What is the treatment for ventricular tachycardia with pulse and hemodynamically stable?

A
  1. amiodarone

2. lidocaine

85
Q

What is treatment for torsades de pointes?

A

Magnesium (as well as treatment for V-tach)

86
Q

What is pulseless electrical activity?

A

a pt without a pulse but normal organized activity on EKG

87
Q

What is the next best step for asymptomatic bradycardia?

A

EKG

88
Q

When should you use a pacemaker in a pt with asymptomatic bradycardia?

A
  1. second degree block type 2 (Mobitz)

2. third degree block

89
Q

What is the treatment for symptomatic bradycardia?

A
  1. IV atropine
  2. transcutaneous pacemaker
  3. dopamine or epineprhine drip
  4. transvenous pacer
90
Q

When would you give a symptomatic bradycardiac pt IV glucagon?

A

due to beta blocker overdose

91
Q

What are the H’s and T’s that can be causes of arrhythmias and asystole?

A
  1. hypoxia
  2. hyper/hypo- kalemia
  3. hypothermia
  4. hypoglycemia
  5. hypovolemia
  6. trauma
  7. toxins
  8. tamponade
  9. tension pneumothorax
  10. thrombosis (coronary or pulmonary)
92
Q

What is the treatment for pt with unstable tachycardia (syncope, SOB, chest pain, confusion)?

A

cardioversion

93
Q

What is the initial diagnostic test for head injury?

A

Head CT without contrast

94
Q

A pt presenting with head injury, spinal tenderness and cervical radiculopathy symptoms should have what additional test along with head CT?

A

cervical spine x-ray

95
Q

A crescent shaped hemorrhage on CT suggests …. due to ….

A

subdural hematoma; shearing of bridging vein

occurs in elderly and alcoholics

96
Q

A lens shaped hemorrhage on CT suggest … due to …

A

epidural hematoma; middle menigeal artery tear due to temporal bone fracture

97
Q

… is diagnosed by a history of loss of consciousness with a negative head CT

A

concussion

98
Q

What is the treatment for stable tachyarrhythmia?

A
  1. beta blockers (avoid if have hx of respiratory disease)

2. calcium channel blockers

99
Q

What is the best initial step in management for a pt with pulseless rhythm?

A

CPR

100
Q

What is the most likely rhythm is pt has irregularly, irregular rhythm?

A

a-fib

101
Q

What is considered chronic a-fib?

A

longer than 2 days

102
Q

What is treatment for a-fib?

A

rate control (beta blockers, calcium channel blockers, digoxin) with anticoagulation (warfarin)

103
Q

What are alternatives for anticoagulation in non-valvular a-fib instead of warfarin?

A
  1. dabigatran
  2. rivaroxaban

(dont require INR monitoring but lack antidote)

104
Q

What is treatment for SVT?

A
  1. vagal maneuvers (carotid sinus massage, valsalva, ice water immersion)
  2. adenosine
  3. beta blockers, calcium channel blockers, digoxin
105
Q

What is treatment for wolff parkinson white (delta wave, PR depression)?

A
  1. procainamide or amiodarone (acute arrhythymia)

2. ablation (definitive)

106
Q

What is the treatment for intracranial hemorrhage (subdural or epidural)?

A

lower intracranial pressure until surgery

  1. hyperventilation –> vasconstriction
  2. elevate head of bed
  3. mannitol
107
Q

What is the next best diagnostic test for a pt with a suspected subarachnoid hemorrhage but a normal head CT?

A

lumbar puncture (red blood cells in last tube or xanthochromia- yellow discoloration of CSF takes 4-6 hours to develop)

108
Q

What treatment is used to prevent vasospasm after a subarachnoid hemorrhage?

A

Nimodipine (calcium channel blocker)

109
Q

Once a pt is diagnosed with a subarachnoid hemorrhage via CT or lumbar puncture, what is the next diagnostic test?

A

angiography to detect location of bleed (tx via embolization or clipping)

110
Q

How does the Glasgow coma scale assess severity of head injury?

A
  1. verbal response (1-5)
  2. eye response (1-4)
  3. motor response (1-6)

(severe < 8)
(moderate 9-12)
(mild > 13)

111
Q

What is decorticate posturing?

A

arms are flexed with hands pointing to cortex

112
Q

What is the best blood pressure for a pt with head injury associated hemorrhage or subarachnoid hemorrhage?

A

SBP 110-160

b/c want to maintain mean arterial pressure above ICP

113
Q

What is the treatment for a spinal headache after lumbar puncture?

A

Blood patch

114
Q

What are common complications of subarachnoid hemorrhage?

A
  1. vasospasm (nimodipine)
  2. hydrocephalus (VP shunt)
  3. re-bleeding (clip)
115
Q

What is ionizing radiation?

A

X-rays or gamma ray:

damages DNA leading to cancer (prevents normal cell replication)

116
Q

What is nonionizing radiation?

A

infrared, UV and microwave radiation

burns not tissue destruction

117
Q

What are side effects of radiation?

A
  1. bone marrow suppression (infections and bleeding)
  2. infertility (especially men)
  3. GI distress (nausea, vomiting, bleeding, infection)
118
Q

What is included in supportive treatment for radiation exposure?

A
  1. antiemetics (zofran)
  2. colony stimulating factor
  3. antibiotics (for infection)
  4. packed RBCs and platelets (bleeding)
119
Q

What are clinical manifestations of electrical injury?

A
  1. cardiopulmonary arrest
  2. neuro effects (motor injury > sensory injury, loss of consciousness)
  3. renal failure (dehydration from fluid sequestration and rhabdomyolysis from tetanic contraction & muscle injury –> myoglobin)
  4. cataracts
  5. fractured bones (tetanic contraction)
  6. skin burns
  7. compartment sndrome
120
Q

What is treatment for electrical injury?

A
  1. pain meds
  2. fluid replacement w/ lactated ringer’s
  3. local wound care
121
Q

What nerve can be injured if child bites on electrical cord getting an electrical shock?

A

labial nerve (may require oral surgeon)

122
Q

What is the treatment for severe anaphylaxis (angioedema, urticaria, itching, bronchospasm, flushed, hoarseness from laryngeal edema, stridor)?

A
  1. epinephrine injection
  2. IV fluids
  3. anithistamine (diphenhydramine)
  4. steroids
123
Q

What is the most common organism associated with cat bites (puncture wound cant be irrigated well)?

A

Pasteurella multocida

124
Q

What organisms are associated with dog bites (rip tearing and crush injury)?

A
  1. Pasteurella multocida
  2. Eikenella
  3. Capnocytophaga canimorsus
125
Q

What is the treatment of choice for cat and dog bite injuries?

A

amoxicillin and clavulanate (augmentin)

used clindamycin with other antibiotic

126
Q

What organisms are associated with human bites?

A
  1. Eikenella Corrodens

2. anaerobes and aerobes

127
Q

What treatment should be done along with prophylactic antibiotics for a human bite?

A
  1. Tetanus (if not vaccinated)
  2. Hep B (vaccine if not vaccinated)
  3. test for HIV
128
Q

What is treatment for bite from animal with suspected rabies (hypersalivation in raccoons, bats, skunks)?

A

post-exposure prophylaxis

  1. Ribavirin
  2. Human rabies IgG
  3. Rabies vaccine (5 shots)
129
Q

What is the treatment for snakebite?

A
  1. immbolize pt (decrease spread of venom)
  2. compression bandage (decrease spread of venom)
  3. antivenom (may have reaction to horse serum)
  4. supportive (fluids and intubation if needed)
130
Q

What factors affect the severity of a snakebite?

A
  1. small body size (kids)
  2. bite on face or trunk
  3. exercising after bite (spreads venom)
  4. deep bite
131
Q

What is considered 1st degree burn?

A

discolored skin that is fully intact without blisters

132
Q

What is considered 2nd degree burn?

A

blister formation

133
Q

What is considered 3rd degree burn?

A

deeper burn that destroys skin appendages (hair follicles, sweat glands, pain receptor)

134
Q

What are signs of respiratory burn injury?

A
  1. soot in mouth/ nose
  2. stridor, wheezing, hoarseness, SOB
  3. burned nasal hairs
135
Q

What is the rule of nines used for adult burn injuries to determine extent of body surface involved?

A

9%: each arm and head

18%: each leg, chest, back

136
Q

What is the complication associated with circumferential burns and what is treatment?

A

tighten and cut off circulation of limb as heal; escharotomy

137
Q

When is a burn considered severe?

A
  1. combination of 2nd and 3rd degree burns involving >20% in adult
  2. combo of 2nd and 3rd degree burns involving > 10% in elderly or kids
  3. 3rd degree burns > 5% of body
138
Q

What is treatment for thermal burns?

A
  1. intubate (if respiratoryinjury)
  2. 100% oxygen if elevated CO
  3. fluid resuscitation w/ lactated ringers
  4. PPI for stress ulcer prophylaxis
  5. silver sulfadiazine (topical abx for infection)
139
Q

How do you determine fluid resuscitation for thermal burns?

parkland formula

A

Volume for first 24 hours = total body surface burned * weight (kg) * 4
-give 1/2 in first 8 hours, 1/4 in 2nd 8 hours, 1/4 in 3rd 8 hours

140
Q

What is goal of fluid resuscitation for thermal burns?

A

urinary output > 0.5-1 ml/kg/hr

141
Q

A pt presents with hypethermia and rhabdomyolysis after anesthesia with halothane/ succinylcholine most likely suffers from …

A

Malignant Hyperthermia

142
Q

What is the treatment for Malignant Hyperthermia?

A

Dantrolene

143
Q

A pt presenting with hyperthermia, muscular rigidity, rhabdomyolysis occurs in a pt using an antipsychotic (haloperidol) most likely suffers from ….

A

Neuroleptic malignant syndrome

144
Q

What is the treatment for neuroleptic malignant syndrome?

A
  1. stop offending drug

2. bromocriptine or dantrolene

145
Q

A pt presenting with hyperthermia, altered mental status and anhidriosis on hot day most likely suffers from …

A

heat stroke

146
Q

What is treatment for heat stroke?

A
  1. IV fluid replacement
  2. rapid cooling (naked, wet, under fan)
  3. cool environment
147
Q

What is the most characteristic finding on EKG for hypothermia?

A

elevation of J wave called Osborne wave

148
Q

What is treatment for hypothermia?

A
  1. external warming (warm blankets/ bed/ bath, heat lamps)

2. internal warming (warmed IVFs/ hemodialysis/ gastric lavage/ humified oxygen)

149
Q

A pt presents with altered mental status, hyperthermia, agitated, muscular hypertonicity, tremor, akathisia after starting or increasing dose of SSRI most likely suffer from …

A

Serotonin Syndrome

150
Q

What are common causes of hypothermia? (5)

A
  1. hypoglycemia
  2. hypothyroidism
  3. sepsis (kids and elderly)
  4. alcohol intoxication
  5. hypoadrenalism

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