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PICU/Tox Flashcards

1
Q

organophosphate poisoning

A 
opposite of anticholinergic (just remember that everything is wet)
Diarrhea
Urination
Meiosis 
Bradycardia
Bronchospasm
Bronchorrhea
Emesis
Lacrimation
Salivation
Sweaty
inhibits acetylcholinesterase, therefore can't stop acetylcholine from binding at the NMJ
muscle fasciculations
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2
Q

examples of organophosphate

A

nerve gas

insecticides

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3
Q

Treatment

A
  1. atropine - competes with acetylcholine, give in boluses, binds receptors
    acetylcholine can’t bind
    works for both organophosphate and carbamate ingestion, target the improvement of resp symptoms
  2. Pralidoxime - breaks the bond between oganophosphate and acetylcholinesterase (frees the enzyme so it can break it down)
    certain bind permanentantly
    only works if used before the permanent bond forms
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4
Q

Side effects of chloral hydrate

A

respiratory depression
in older kids, unreliable absorption >3 years old
chapter in nelsons

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5
Q

midazolam

A

hypotension
respiratory depression
paradoxical reaction (20% of kids)

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6
Q

Side effects of propofol

A

hypotension
propofol infusion syndrome
- if you use for longer than 12 hours in child
- associated with hemodynamic collapse, cardiac failure, shock and death
hypoventilation
use with caution in hemodynamic unstable and patients
also in kids with egg and soy patient

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7
Q

Reye’s syndrome

A

mitochondrial hepatotopathy
liver failure leads to encephalitis
Aspirin and viral infection (influenza and varicella)

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8
Q

Reye’s syndrome

A 
Increased LFTs and NORMAL bill and NO jaundice 
coagulopathy
high anemia
NO TREATMENT FOR REYE SYNDROME
may need liver
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9
Q

Lightening

A

Systems affected by lightening

  • cardiovascular - most likely
  • respiratory
  • neuro - cerebral edema, seizures
  • kidneys - can get renal failure - can get rhabdo and myoglobinuria
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10
Q

High tension electrical wire burns , climbed a tree then fell on ground

A

ABCDS
entry point and exit point - will have two holes, could have injuries anywhere on the pathway
exit point usually on the legs (first part of the body that touches the ground)
also want to look for compartment syndrome
bowel perforation, liver and spleen hemorrhage
need CT scan
early debridement, tetanus prophylaxis, give aggressive hydration, regardless of how good a patient looks, have to admit them because of possible deep injury takes time to present

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11
Q

Girl who bit electrical cord, mucosal burn on side of mouth

A

don’t have to admit
doesn’t result in conduction of electricity elsewhere
localized burn, don’t extend, since entry/exit are right there
lower voltage

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12
Q

cholinergic toxidrome

A

treat with atropine
(the other option is pralidoxime but more conditions about when it works and only works for organophosphate poisoning (not carbamate)

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13
Q

What is physiostigmine?

A

CHOLINERGIC

used to treat anticholinergic

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14
Q

What is the most important complication of hydrocarbon poisoning

A

lung shit
can’t make surfactant therefore get an ARDS type picture
aspiration

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15
Q

what is sudden sniffing death?

A

heart explodes after sniffing volatile hydrocarbons
myocardium extra sensitive to catecholamines
if they are sniffing and then cause catecholamine release then heart explodes
sudden sniffing death
usually refractory to shocking

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16
Q

if patient with sniffing and cardiac arrest, VF, shocking no help, what to do?

A

beta blocker can try to block B2 receptors

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17
Q

activated charcoal when do you not use

A
  1. hydrocarbons
  2. alcohols
  3. iron
  4. heavy metals
  5. caustic agents - alkali/acids
  6. Lithium

*anything that’s liquid probably aint gonna work
plus heavy things

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18
Q

gastric lavage evidence in ingestions?

A

poor

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19
Q

Classes of hemorrhage?

A 
class i: lost 15% of blood, children can tolerate that, no vital signs changes
class II: lost 15-30% of blood, tachycardia, certain decreased perfusion (slight slow CRT)
class III: 30-40% blood loss, moderate to severe increased HR, BP may start to drop, u/o drops, start to get shock
class IV: >40%, comatose, lose consciousness , essentially dying

used to determine how fast to give blood
I or II: can consider giving 2 boluses first - 1-2 L, if better then rapid responder, don’t need to give them anything else ; if after 15 minutes still having trouble then transient responder, give blood
if III or more: as soon as you have blood, give it (waiting for blood then give something (even if fluids)

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20
Q

most common injury of severe head injury

A

specific learning disability high rates, 2/3 have ADHD

epilepsy 2%

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21
Q

when can you give activated charcoal

A

within 1 hour

if anticholinergic or slow release then might want to give later

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22
Q

when to not reverse diazepam

A

not if seizures or long use

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23
Q

Hemorrhagic shock and encephalitis syndrome (HSES)

A

super high fever
rare
prodrome of fever, URTI sx then hemorrhage etc.

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24
Q

Dog bites infections

A

anaerobes
kingella kingae
capnocytophaga

pasteurella (less likely)
staph and strep
prophylax if on hands (some controversy about when to prophylax)
What big nelson says about dog bites:
types of bites: abrasion, puncture, laceration with or without tissue avulsion
Most common complication: infection ; however infection rate of wounds brought to medical attention 24 hours should not suture them
all hand wounds HIGHLY likely to get infected - so delayed primary closure for all
vs primary closure for facial
very little evidence of anti-microbial agents for prophylaxis of bite injuries - should give Abx to all human bites, and all but most trivial of other bites
also assess tetanus, rabies, hep B/HIV (human)

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25
Cats
pasteurella - most likely polymicrobial, but if isolate something pasteurella most likely staph and strep cat bites more likely to be infected than dog bites (at least 50%) therefore need to culture these unless very trivial
26
where do you need operative management?
1. closed fist injury 2. head injury 3. extensive wound with lots of dead tissue
27
which fun drug causes nystagmus
PCP
28
what are 3 non recreational drugs that can cause nystagmus
1. ketamine - eyes go crazy with procedural sedation 2. barbiturates 3. phenytoin toxicity other ones: (baby nelson) ethanol, carbamazepine, dextromethorphan
29
violent/agitated due on cocaine comes into er
physical restraints worsens agitation and hyperthermia knock them out with benzos suppotive care and glucose level
30
swimming and swallowing lots of water
get hyponatremia and then can seize
31
CPS statement
no evidence that lessons prevent drowning, just familiarizes them with water
32
specific fractures for child abuse
1. posterior rib fracture 2. proximal humeral 3. femur fracture in non ambulatory 4. scapula spinal process fracture 5. metaphyseal distal femoral metaphyseal
33
Concussion
short lived impairment of neuro function which resolves resolves within 7-10 days usually 4 kinds of categories of features: - only need one of the features - history, behaviour, n/v/vomiting, cognitive, sleep disturbances
34
Jimson Weed
atropine and scopolamine, can increase temperature, increases HR, pupil dilatation, photophobia , amnesia
35
TCA overdose
1-2 pills can be enough anything above 20 mg/kg can have series effect blocks fast acting sodium channels impairs cardiac function, get arrythmias get wide QRS, PVCs, if present with hypotension then poor prognosis, leading cause of death
36
Treatment of TCA overdose
within 1 hour charcoal | urinary alkalization with Na HCO3 if QRS long, hypotension or arrhythmia
37
Progression of transtentorial herniation
``` ipsilateral 3rd nerve palsy contralateral palsy dilation of the other pupil then altered rhythm after breathing get bradycardia hypotension is the last step decorticate and decerebrate ```
38
CPS statement if no IV
intranasal (0.2 mg/kg), IM (0.2/kg), buccal midaz (0.5mg/kg with max 10) diazepam - rectal 0.5 mg/kg ativan - buccal or PR 0.1 mg/kg max 4 mg
39
Traumatic Brain Injury
``` 1st tier: sedation and analgesia elevate the head of bed hyperosmolar agents 2nd tier: treat fever - can increase metabolic needs not too hot and not too cold also talk about CSF drainage and hyperventilation ```
40
Which sedative can help in asthma
ketamine, it is also a bronchodilator dissociates the connection between cortex and limbic system Hypnotic effect, amnestic effect
41
septo optic dysplasia with hypo pit
iv hydrocortisone don't need mineral corticoid ACTH is only the glucocorticoid renin aldosterone
42
ABCDEs be safe - admit everyone and do as much as you can for them think about common and what you can't miss
asdf
43
toxicology
often we just watch - do NO harm
44
work up for toxic ingestion
``` glucose lytes renal LFTs serum osmoles blood gas levels: ethanol, acetamiophen, ASA Others: toxic alcohols, meds EKG urine tox (debatable) ```
45
Charcoal
decreases absorption usually use within 1 hour (remember that tylenol works quickly, should be out of stomach after 1 hour) know what you're trying to get out
46
When to not use charcoal
Hydrocarbons alcohols iron electrolytes mineral acids or bases **basic - neutralized in belly, if drank javex don't want to vomit Patient factors:obtunded, loss of airway reflexes, vomiting, non toxic ingestions never give via NG unless patient is intubated or if it is one of the ingestions that MUST get out - always risk of aspiration
47
When to do whole bowel irrigation and gastric lavage
asdf
48
Toxidromes
1. anticholinergic 2. Cholinergic 3. opioid 4. sympathomimetic 5. sedative hyponotic (same as opioid except not teeny pupil)
49
Jimson weed vs TCA
jimson weed makes you hallucinate more
50
Anticholinergic
``` TCA antihistamine antipsychotic antidepressants atropine (decreased bowels) ```
51
Treatment of anticholinergic
supportive Sodium bicarb for prolonged QRS, dysrythmias physostigmine if altered LOC - can make arrhythmia worse (also, relatively contraindicated for TCA according to Nelson) benzos for seizure
52
Cholinergics
``` mushrooms pesticide nerve gas DUMBELLS (aka SLUGDE and the killer Bs) **everything is wet ```
53
Treatment of cholinergic
decontaminate supportive atropine - works for both organophosphate and carbamate 2-PAM (pralidoxime) - only works for organophosphate, and only if perm bond hasn't formed yet
54
Opiates
``` morphine, heroine, methadone sedation, confusion, coma miosis hypopnea, bradypnea, resp depression, bradycardia, hypothermia, hypotension Treatment: suppotive, naloxone if respiratory depression fentanyl wears off in an hour methadone very long morphine few hours ```
55
benzos
treatment: suppportive rarely flumazenil - if you gave the benzo and resp depression **causes seizures (can precipitate seizures, don't give with seizures)
56
Toxic alcohols
ethylene glycol and methanol are the scary ones - the metabolites are the worry, stop metabolite formation with fomepizole IV (shuts down the enzyme) (or ethanol) think osmole gaps and anion gaps send specific ethanol and isopropyl alcohol (makes you drunk but otherwise okay) since will convert ethanol before ethylene glycol
57
Osmolar gap and anion gap graphed over time of post-toxic alcohol ingestion
for alcohols - as alcohol gets metabolized they create other stuff that is counted for in the anion gap EARLY: osmolar gap increased with nomad anion gap Late: elevated anion gap with a normal osmolar gap osmole gap: 2 x [Na mmol/L] + [glucose mmol/L] - 2 salts and a sticky bun over the course of hours usually normal Osmolar gap is <10 as per wiki
58
Acetaminophen
``` do levels 4 hours post, plot on Rumack Matthew 4 stages: preinjury liver injury maximum liver injury recovery use antidote within 8 hour no adverse events often asymptomatic ```
59
salicylates
tinnitus, hyperventilation, respiratory alkalosis increased HR, decreased BP, arrhythmia, CNS depression, tremor, seizures salicylate levels - until they peak and then at least 2 decreasing ones examples is ASA and wintergreen only way to get rid of it, dialyse it can dialyze can alkalinize the urine (not the best evidence)
60
most unknown things
suppotive management, observe 4-6 hours if asymptomatic | benzos for agitation, hallucinations
61
other common ingestions
lead ingestion iron SSRIS
62
killers in small doses
oral hypoglycemics, beta blockers, CCa blockers, TCAs, quinine, opiates, salicylates, loperamide and diphenyoxylate, camphor, podophyllin
63
symptom of ASA overdose
either renal failure or potassium
64
TRAUMA
think about location remember the golden hour basic principles apply - treatment guidelines are very different 100% O2 plus/minus intubation, 2IVs for all trauma patients IO if not, NS fluid, platelets and FFP if more than 1-2 units of blood D - GCS and pupils C spine primary and secondary surveys
65
trauma panel
CBC, coags, type and screen, lutes, LFTs, renal function, amylase, lipase urinalysis for gross hematuria consider - serum ethanol and other toxins, urine fox screen imaging CXR ,C spin, consider FAST /CT scan
66
hyperventilate
only if in tertiary care centre otherwise you are screwed anyways
67
which pneumos do you need to treat in resus
open/tension hemo- can be massive cardiac - blunt/tamponade vessel injury
68
organs for trauma
1. liver 2. spleen 3. kidneys 4. pancreas occasionally bowel (seatbelt injuries, handlebars)
69
how to decide what to do for abdo trauma
unstable surgery | if stable can do some imaging (i.e. fast)
70
indication for laparotomy
HD instability with evidence of abdo injury penetrating injury to abdo pneumoperitoneum multisystem trauma and need other OR procedures if evidence of abdo injury
71
Orthopedic trauma
can kill you - neck and back and paralyze you can bleed - pelvis/femurs - they bleed the rest are less important assess neuromuscular status try to restore anatomic alignment, splint, consult, orthopaedic service
72
gunshot wounds
think of trajectory | need a surgeon
73
stab wounds
location depth need to be explored - bedside or OR
74
burns
``` 100% O2 early intubation on exam - Parkland formula in real life goal directed : urine output, peripheral perfusion D and E provide analgesia rule out other trauma ```
75
Burns
calculate BSA 2nd and 3rd | admission: analgesia, BSA >10% location of face, genitals, joints, circumferential, any inhalational burns, child abuse
76
Carbon monoxide poisoning
carboxyhemoglobin levels mild 5-20% - h/a confusion, dyspnea moderate 20-40 % drowsy, N/V, tachy severe
77
treatment
100% O2 until levels <5%, if anemic transfuse to 100, hyperbaric oxygen, CNS symptoms, CVS symptoms, pregnancy consult a hyperbaric physician
78
near drowning
drown if cold | continue resus and rewarm
79
near drowning
not dead till warm and dead rewarm aggressively until 34 C, warm IV fluids, external warmers, consider lavage (chest, bladder, abdo) CPR continuously, epi, shock if rhythm allows Don't forget - C spine injuries, head trauma **shock and epi not likely to work until 28 C continue CPR and warm until
80
bad prognosis in drowning
> 10 minutes submersion | >25 minutes CPR
81
Foreign body
in the airway : upper -need to get out emergently - stridor, drooling, tripoding, complete obstruction lower - removal, urgency based on symptoms suspect if: history suggests if, clinical history suggests it CXR suggests it
82
GI tract
only care if in the esophagus - drooling, vomiting, vomiting, dysphagic, FB sensation most will pass after observation consult speicalist for removal, if abnormal esophagus consult
83
esophagus button batteries
perforation secondary to burn, not if lower down (some controversy) need a specialist -
84
most things pass
sharp, long >5 cm button batteries can be observed once here multiple magnets must be removed follow up XR only if signs of obstruction, abdo pain
85
X-rays for FB
``` FB inspiratory/expirtaory films fluoroscopy metal detectors lacerations - location, depth, involved structures close everything with suture glue if linear, short (<5 cm) not under tension, not for bites, crushes, punctures, mucosal laceration complete irrigate with water -tap ok antibiotics if dirty ```
86
Tetanus
are they up to date? how dirty is the wound? | 3 doses or more 10 years - give vaccine
87
kid bit by a dog - everyone has vaccine
``` management who/where/why who did the bite - why? provoked/unprovoked tetanus status air on the side of treating amox/clav only close if cleaned very well or on the face ```
88
Types of wounds to start antimicrobial therapy:
(essentailly all but most tribal) 1. moderate or severe wounds 2. puncture wounds 3. facial bites 4. hand and foot bites 5. genital bites 6. wounds in immunocompromised or asplenic people 7. wounds with signs of infection
89
Sedative agents
from our notes: midazolam - short acting benzo, amnestic effects ketamine - hypnotic effect, amnestic effect, hallucinogenic effect, can last for weeks, is a bronchodilator
90
Selected drugs used in anaesthesia (table 70-5 e-Nelson)
see notes

PICU/Tox (3 decks)

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