Emergency Medicine Flashcards
describe treatment of anticholinergic overdose
consider charcoal if conscious
if hypotension
- fluids
- glucagon
- noradrenaline
give sodium bicarbonate if
- acidosis
- QRS >120 ms
- hypotension unresponsive to fluids
- ventricular arrhythmias
intralipid
Describe anticholinergic toxidrome
“Blind as a bat, dry as a bone, red as a beet, hot as a desert”
- flushing
- dry skin and membranes
- mydriasis and loss of accommodation
- clonus
- confusion
- hyperthermia
- tachycardia
- absent bowel sounds
- urinary retention
- constipation
e.g. tricyclic antidepressants (TCAs like amitriptyline), antipsychotics, antihistamines
> metabolic acidosis
> convulsions
> hypotension with dysrhythmia (mostly tachycardia)
> airway loss if obtunded
describe a cholinergic toxidrome
muscarinic symptoms: SLUDGE
- salivation
- lacrimation
- urination (increased)
- defecation (diarrhoea)
- GI cramping
- emesis (vomiting)
nicotinic symptoms: MTWTF
- muscle cramps
- tachycardia (or bradycardia in muscarinic)
- weakness
- twitching
- fasciculations (check tongue)
other symptoms
- miosis
- sweating
- seizure risk
- bronchorroea
- bronchospasm
most common cause - organophosphate insecticides, pesticides
also donepizole and overdose of agents used in myasthenia gravis e.g. pyridostigmine
also novichok nerve agents
antidote - atropine, pralidoxime
describe sympathomimetic toxicity
- airway compromise less common unless rigid
- tachypnoea
- hypertension and tachyarrhythmias
- mydriasis, seizure, psychosis
- hyperthermia
causes: cocaine, MDMA, significant caffeine, amphetamines, theophylline excess in asthmatics
remember to monitor CK and myoglobin
> early ECG if chest pain
management
- charcoal if theophylline poisoning only
- benzodiazepines e.g. diazepam if agitation/confusion
- avoid beta blockers
- cool by any means possible then IV dantrolene
- sometimes sodium nitroprusside for hypertension
describe sympathomimetic serotonergic crisis / baclofen withdrawal
also caffeine, theophylline, SSRIs/SNRIs, GHB, MDMA
- rigid jaw and airway compromise
- tachycardia, hypertension, tachypnoea
- cardiovascular collapse
- acidosis
- hypertonicity with clonus
- confused and agitated before coma
- refractory hypoglycaemia
- seizures
- rhabdomyolysis with K>10
- malignant hyperthermia
management
- intubation (without fentanyl)
- large amounts of benzodiazepines
- aggressive cooling
- cyproheptadine orally or NG
- chlorpromazine IM
describe opioid toxicity
- airway compromise
- hypoventilation and hypoxia
- hypotension and bradycardia
- reduced GCS and pinpoint pupils
- hypothermia
management
- naloxone (half-life 30 or 45 mins)
> naloxone infusion if modified release like MST
- supportive care
describe sedative / hypnotic toxicity
e.g. alcohol, benzodiazepines
- airway loss if obtunded
- respiratory compromise
- cold
- hypotension, bradycardia
- mydriasis
- dizzy, dysarthric, drowsy and ataxic
management
- watch for withdrawal (seizures)
- supportive treatment
- flumazenil only rarely
describe a paracetamol overdose
presentation
- early: nausea and vomiting
- late (3-4 days):
> nausea and vomiting
> hepatic necrosis
> hypoglycaemia
> cerebral oedema
> encephalopathy, coma, death
if plasma level >700 mg/L (rare) - different presentation
> sedation
> coma
> high lactate
list adverse effects of N-acetylcysteine
- nausea
- urticaria
- erythema
- bronchospasm
- angioedema
- anaphylactoid reaction
describe beta blocker overdose
- bradycardia
- hypotension
- prolonged QTc
- cardiogenic shock: VF/VT
- coma
- seizures
- propranolol: bronchospasm
management
- activated charcoal if <1h
- 8.4% sodium bicarbonate
- atropine
- IV glucagon
- consider inotropes
- intralipid if propranolol
- ECMO
cardiac pacing ineffective
describe calcium channel blocker overdose
- sinus bradycardia
- hypotension
- prolonged QTc
- high K, low glucose
- cardiogenic shock: VF/VT
Management
- activated charcoal if <1h from ingestion
- calcium chloride
- insulin (aim for hyperinsulinaemic euglycaemia)
- 8.4% sodium bicarbonate
- intralipid
- inotropes
- ECMO
describe digoxin toxicity
- QTc prolongation
- bradycardia
- “reverse tick” on ECG
- metabolic acidosis
- hyperkalaemia
- nausea, vomiting
- confusion
management
- stop digoxin
- charcoal
- sodium bicarbonate
- insulin/dextrose for hyperkalaemia
- atropine
- give digibind if plasma level > 10 nmol/L
- cardiac pacing
- ECMO
describe iron toxicity
- nausea, vomiting
- abdominal pain
- diarrhoea
- haematemesis
- acidosis
- potential for late deterioration with hepatic necrosis
- worse in children
treatment
- gastric lavage
- endoscopy
- desferrioxamine
- dialysis
describe cannabinoid hyperemesis
- cyclical vomiting
- relieved by hot water over 41 degrees
- standard antiemetics may not work
- management
> capsaicin cream
> haloperidol
describe the RUSH protocol and HI-MAP approach
RUSH protocol
- pump: LV contractility, RV strain, tamponade
- tank: IVC variation, leaks, tank compromise
- pipe: aortic dissection, aneurysms, DVT
HI-MAP approach
- heart
- IVC
- Morrison’s pouch and E-fast
- aorta and deep veins
- pneumothorax, PLE, PN, pulmonary oedema
