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Flashcards in EM Deck (51):
1

These 3 methods are ALWAYS wrong for ingestion overdose?

1) Ipecac
2) Forced diuretics
3) Cathartics (sorbitol)

2

What are 2 common presentations of altered mental status of unknown etiology in the ER? What is best initial treatment?

Opioid OD
Hypoglycemia

Tx: naltrexone & glucose

3

Do you need to give flumazenil to benzo overdose?

NO - this OD is NOT fatal and acute withdrawal can cause seizures!

4

What is always given to someone with a pill overdose?

Charcoal

When you don't know what to do in toxicology = give charcoal

5

What is toxic dose of acetaminophen?

8-10g

6

If a clearly toxic amt of acetaminophen is ingested (8-10g), what is best initial treatment?

N-acetylcysteine

7

If acetaminophen has been OVER 24 hours, what is best initial therapy?

NOTHING

8

If amt of acetaminophen ingestion is unclear, what is next step?

Get a drug level

9

Can you use charcoal with N-acetylcysteine?

YES

10

What 3 findings are seen with aspirin overdose?

1) Tinnitis
2) Respiratory alkalosis (compensation for increased acid level)
3) Metabolic acidosis (aspirin blocks oxidative phosphorylation and results in increased anaerobic respiration = increased lactate = AG metabolic acidosis)

11

Treatment for aspirin overdose?

Alkalinize the urine --> increases rate of aspirin excretion

12

What are the 2 most severe finding in TCA overdose?

Seizures
QT prolongation --> leading to arrhythmia

13

What other effects of TCA overdose can be seen?

Anti-ACh side effects --> dry mouth, constipation, urinary retention

14

Treatment of TCA overdose?

What is it's MOA?

NaHCO3

TCA normally (-) fast Na channels in His-Purkinje system and myocardium. This causes the QRS prolongation and arrhythmias.

**NaHCO3 protects the heart by decreasing drug avidity for Na channels on the heart --> elevated Na concentration now increases the electrochemical gradient across cardiac cells and affects the ability of TCA to bind to fast Na channels

15

In caustic ingestions what are you NEVER supposed to give?

Acids or alkali to try and reverse what was initially ingested --> this will only cause extra damage from exothermic reaction

16

What damage is caused by caustic ingestions?

Mechanical damage to oropharynx, esophagus, stomach

*Look for perforation

17

Treatment for caustic exposure?

Flush out fluids w/ excess water

18

What scenarios should suggest CO poisoning?

Gas heater
Wood burning stove
Automobile exhaust

19

CO effect on RBCs?

CO binds O2 to Hg so tightly that carboxyhemoglobin will NOT release O2 to tissues --> acts functionally like anemia

20

Patient presentation w/ CO poisoning or methemoglobinemia?

Dyspnea
Lightheadedness
Confusion

21

Cause of death from CO poisoning?

MI

*Decreased O2 delivery to heart muscle --> lactic acidosis forms and tissue dies

*Metabolic acidosis results!

22

Can pulse oximetry be trusted with CO poisoning & methemoglobinemia?

NO

23

What is pO2 level in CO poisoning & methemoglobinemia?

NORMAL (remains bound to hemoglobin)

24

Most accurate test for CO poisoning?

Carboxyhemoglobin level

25

Best initial therapy in CO poisoning & methemoglobinemia?

Give 100% oxygen

*Severe disease treated with hyperbaric oxygen --> only if CNS symptoms, cardiac symptoms, or acidosis present

26

What drugs can result in methemoglobinemia?

Anesthetics (local - benzocaine, lidocaine)
Nitrites (nitroprusside, nitroglycerin)
Dapsone

27

Most accurate test for methemoglobinemia?

Methemoglobin level

28

Methemoglobinemia:
- Best INITIAL therapy?
- MOST effective therapy?

Best initial = 100% O2
Most effective = Methylene Blue

29

What is color of blood in CO poisoning? Methemoglobinemia?

CO poisoning = bright/cherry red
Methemoglobinemia = brown

30

Cyanosis + normal pO2 is what?

Methemoglobinemia

31

If someone has a head injury, what prophylactic medication must they be given? Why?

PPI

*Prevent stress ulcer formation in stomach --> Cushing ulcer

32

What substance should you consider with ingestion of windshield wiper fluid?

What s/s will you see?

Lab findings?

Tx?

Methanol

**BLURRY VISION/BLINDNESS (formic acid is a degradation product of methanol that causes direct toxicity in optic nerve)

Anion gap
Metabolic acidosis

Tx: fomepizole (ADH inhibitor)

33

Gunshot wound to neck - what is best management?

Exploratory surgery AFTER most accurate knowledge of location and extent of injuries --> diagnostic studies should be done (angiogram, esophagogram, esophagoscope, bronchoscopy)

34

S/S of mercury poisoning?


Tx?

Diarrhea
Constricted visual fields
Renal failure
Tachy
HTN
Peripheral neuropathy
Hyperhidrosis

Tx: succimer, dimercaprol, penicillamine

35

What 2 harmful substances must you address in smoke inhalation injuries (fire victims)?

Cyanide & CO

Tx of cyanide: hydroxycobalamin or sodium thiosulfate or nitrites (induce methemoglobinemia)

36

With cyanide, why do you get high levels of LDH produced?

Cyanide inhibits ETC in mitochondria --> blocks ATP formation from oxidative phosphorylation --> cells have to utilize anaerobic metabolism

37

What finding on Xray can give you a clue to diaphragmatic rupture?

NG tube in the L chest cavity (follow trachea down and the NG tube will then coil up into the chest cavity)

38

3 complications of TCA overdose?

Cardiac arrhythmia
Convulsions (seizures)
Coma

39

Treatment of choice for anaphylactic shock?

IM epinephrine

NEVER IV b/c of risk of arrhythmias!

40

Person is taking theophylline. What is it's metabolism? What drugs must you be careful taking with theophylline?

Cytochrome oxidase P450 in liver

**Meds that inhibit CYP450 will cause toxicity
- Cimetidine, Cipro, Erythomycin, Clarithromycin, Verapamil

S/S: CNS stimulation (HA, insomnia, seizures), arrhythmias

41

Patient had MVA. Despite 2L IV fluids, he remains at 80/40, HR of 120, and has JVD. Why is the cause? Next best step?

Pericardial tamponade


Pericardiocentesis

42

What OD is manifested by hypotension, bradycardia, AV block, and diffuse wheezing?

First line tx?
Tx for refractory hypotension and bradycardia?

B-blocker OD --> WHEEZING most specific
*can progress to cardiogenic shock

1st line: IV fluids + atropine (break the brady)
Refractory: Glucagon

43

What is the timeframe to use charcoal in Acetaminophen OD?

Less than 4 hours after ingestion

44

Smoke inhalation exposure in people with HA, nausea, and abdominal discomfort - what do you suspect? What other exam finding is present? What is best initial test?

CO poisoning
Pink-red skin coloring
Carboxyhemoglobin level

45

Appropriate treatment for frostbite?

RAPID re-warming with WARM water --> immersed in warm water

46

45 yo homeless man presents to the ER with epigastric pain, vomiting, and being confused. He complains of vision loss and his fundoscopic exam shows optic disc hyperemia. His labs are:
Na - 136
K - 3.0
Cl - 93
HCO3 - 6

What is the cause of his symptoms?

Methanol

*Metabolic acidosis with severe HCO3 loss

*Can lead to vision loss --> optic disc hyperemia

*Blurred vision, epigastric pain, vomiting, hyperemic optic disc

47

40 yo man is brought to ER in confused state. He attempted to OD, but doesn't remember the drug. He is drowsy with blurred vision. Temp is 100 but other vitals are normal. Mucus membranes are dry and pupils are 8mm b/l. Reduced bowel sounds heard and he has urinary retention. What is the agent?

Diphenhydramine (anti-histamine + anti-muscarinic)

48

Why are B-blockers CONTRAINDICATED in allergy testing?

If anaphylaxis occurs --> only treatment is EPINEPHRINE
*B-blockers will cause epinephrine to be ineffective!

49

What drug is CONTRAINDICATED in cocaine overdose with anginal pain?

B-blockers
*Cause unopposed alpha-agonist activity that can worsen the vasospasm!

50

What 2 conditions are B-blockers never the first treatment?

Cocaine overdose
Pheochromocytoma

*Unopposed alpha stimulation would cause increased HTN/vasospasm

51

What are common signs of marijuana intoxication?

*Increased appetite
*Dry mouth
*Conjunctival injection