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80 Cards in this Set
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most important step in managing acute change in mental status of unclear etiology, suicide attempts is to |
administer antidotes such as naloxone, dextrose, thiamine (due to hypoglycemia or opiate as cause of mental status), oxygen and normal saline all at the same time while checking for toxicology screen |
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when to answer gastric emptying |
useful only in first hour of overdose...so be sure! 1hr can remove 50% of pills, 2hours-15%, >2hrs is useless |
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what answers are always wrong |
1. gastric emptying except first 1 hour 2. never use gastric emptying for caustics (acids and alkalis) and altered mental status-aspiration 3. Ipecac is never used in children and patient with altered mental status 4. intubation and lavage if no response to naloxone, thiamine and dextrose within the last 2hrs |
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when to give charcoal |
when you dont know what to do it always helps in overdose and does not harm |
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antidote of acetaminophen |
N-acetyl cysteine (NAC) |
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aspirin overdose |
bicarbonate to alkalinize the urine |
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benzodiazepines overdose |
do not give flumazenil, it may precipitate a seizure |
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carbon monoxide poisoning |
100% OXYGEN, HYPERBARIC IN SOME CASES |
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digoxin overdose |
digoxin binding antibodies |
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ethylene glycol overdose |
fomepizole or ethanol |
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methanol poisoning |
fomepizole or ethanol |
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methemoglobinemia |
methylene blue |
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neuroleptic malignant syndrome |
bromocriptine, dantrolene |
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opiates poisoning |
naloxone |
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organophosphates poisoning |
atropine, pralidoxime |
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tricyclic antidepressants overdose |
biocarbonate protects the heart |
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management of acetaminophen poisoning |
acetaminophen-24hr-vomitng and nausea, 48-72hr- hepatic failure, 10gis toxic, 15g is fatal give NAC and charcoal to all patients within 24 hours, with high benefit and >24 hr with lower benefit or no therapy IV NAC for vomiting patients then check for level of acetaminophen |
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when to use Ipecac |
at home, immediately after accidental ingestion before coming to the hospital it requires 15-20mins to work and delays administration of medication |
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what not to do in emergency poisoning |
1. no cathartics-speeding up GI transit time 2. forced diuresis-cause pulmonary edema 3. gastric emptying of any kind-caustic, acetaminophen, altered mental status 4. whole bowel irrigation only in smuggling, heavy iron ingestion and lithium |
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two most common cause of overdose especially if cause is unknown |
acetaminophen and aspirin |
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an overdose question with tinnitus is likely |
aspirin |
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signs of aspirin poisoning |
1. tinnitus and hyperventilation 2. respiratory alkalosis progressing to metabolic acidosis (from lactate) 3. renal toxicity and altered mental status 4. increased anion gap 5. ARDS 6. interfers with prothrombin time |
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PH balance in aspirin overdose |
respiratory alkolisis and metabolic acidosis norm; PH 7.40, pCO2 40, HCO3 24 PH 7.46, pCO2 22, HCO3 16 for example, see that respiratory alkalosis is not a compaensation of metabolic acidosis, since PH is alkalosis and HCO3 is acidosis give biocarbonate to increase excretion of aspirin |
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cause of primary metabolic acidosis with respiratory alkalosis as compensation |
CO poisoning, sepsis, uremia and DKA |
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primary respiratory acidosis |
COPD |
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tricyclic toxicity |
siezures and arrhythmias leading to death signs of anticholinergic-dry mouth, constipation and urinary retention best inital test is ECG-torsades with widening of QRS complex Rx- sodium bicarbonate to protect the heart from arrhythmia only |
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treatment of caustic ingestion |
flush out with high volumes of water then perform endoscopy to asses the degree of damage |
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dyspnea, confusion, lightheadedness, MI->death |
CO poisoning, LV cannot distinguish between anemia and Carboxyhemoglobin (oxygen is picked up but not released to tissues) and lead to stenosis of coronary arteries give hyperbaric oxygen for severe cases like this (CNS, cardiac, and metabolic acidosis) 100% oxygen for minor cases |
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management of methemoglobinamia (brown blood) |
oxygen is not picked up at all leading to hypoxia same symptoms as carboxyhemoglobin (red blood) causes are nitrates and anesthetics, daapsone and nitroglycerin normal pO2 on blood gas test-methemoglobin level initial therapy-100%oxygen most effective therapy-methylene blue |
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cyanosis + normal pO2 |
methemoglobinamia |
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signs or nerve gas and organophosphate poisonig (both are absorbed through the skin) |
salivation, lacrimation, urination, defecation, bronchospasm, secretions Rx-atropine (blocks acetycholine already released) for nerve gas and organophosphatee for instant relief pralidoxime (reactivates acetycholinesterase) for prganophosphate |
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managment of digoxin poioning |
initail-check potassium and EKG-downsloping of ST segment and arrhythmia most accurate-digoxin levels treatment-digoxin-binding antibodies hypokalemia->digoxin toxicity digoxin toxicity->hyperkalemia |
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signs of lead poisoning |
wrist drop sideroblastic anemia memory loss lead colic (abdominal pain ATN best initial test-protoporphyrin level, most accurate is lead level best initial for sideroblastic-Prussian blue stain treatment-succimer orally, EDTA and dimercaprol IV |
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mercury poisoning managment |
interstitial fibrosis nervous and jittery, twitchy and hallucination give succimer and dimercaprol are effective but cannot reverse fibrosis |
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what causes death from snake bite |
hemolytic toxin-hemolysis and DIC neurotoxin-respiratory paralysis, ptosis, dysphagia and diplopia rx-pressure (not tourniquets blocking arterial flow) immobilization decrease movement of venom and give Antivenin |
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managment and presentation of two types of spider bites |
black widow- abdominal/muscle pain, lab-hypocalcemia, Rx-calcium, antivenin brown recluse-local skin necrosis, bullae and blebs, no lab, rx-debridement, steroids and dapsone all will describe sudden sharp pain like stepping on a nail |
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managemnet of human, dog and cat bite |
amoxicillin/clavulanate tetanus vaccination booster if more than 5 years since last injection Rabies if animal has altered mental status or stray dog human bites are worse-Eikenella corrodens dog and cats=pasteurella multocida |
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tratemnt of head trauma |
first do non contrast CT 1. then if concussion- no specific therapy, home observation, wait 24hr before returning to sports 2. cotussion, no need 3. subdural and epidural (both has lucid interval-loss of consciousness) intubation and hyperventilation(it dec pCO2, which dec cerebral flow, slows herniation and a bridge to surgery), mannitol and drainage |
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indication for stress ulcer prophylaxis with PPIs |
head trauma burns endotracheal intubation coagulopathy (platelet <50,000 and INR >1.5) with respiratory failure after surgery of epidural or subdural, start PPIs |
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indication for nimodipine |
subarachnoid hemorrhage to prevent stroke |
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indication for steroids |
decrease edema around mass lesions |
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best initial therapy for burns with fire |
100% oxygen to treat CO poisoning and smoke inhalation intubation if airway injury and fluid replacement by body surface area (volume loss is second most common cause of death in burn patients) |
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indication for intubation in burns |
stridor hoarsness wheezing burns inside the nasopharynx or mouth |
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how to replace fluid in burn |
4ml * %BSA* weight in kg head=9% BSA Arms=9% BSA legs= 9% BSA chest or back = 18% BSA each give Ringer lactate or normal saline |
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most common cause of death after burn |
lung-immediate infection several days by staphylococcus (prevent with topical silver sulfadiazine antibiotics) |
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management of cardiac arrest |
1. ensure unresposiveness not syncope or sleeping 2. call for help and 911, activate EMS 3. open the airway;head tilt, chin lift, jaw thrust 4. give rescue breath if not breathing 5. check pulse and start chest compressions if pulseless |
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indication for precordial thump |
less than 10 minutes of pulselessness, you 'witnessed it happen" |
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cause and best initial treatment for pulselessness |
1. asystole 2. ventricular fibrillation 3. ventricular tachycardia (VT) 4. pulseless electrical activity (PEA) |
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sign on ECG for hypothermia |
J waves (where QRS hit ST segment) patients are usually intoxicated, with low body temperature |
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indication for unsynchronized cardioversion |
VT and VF only |
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Rx of asystole |
CPR, epinephrine or vasopresin |
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best initial therapy for Vfib |
unsynchronized cardioversion (defibrillation) folowed by CPR then another defibrillation, then epinephrine and another shock give amiodarone to aid shock to be successful vfib=shock, drug, CPR, shock, drug, CPR, shock, drug |
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management of Vtach |
1. if pulseless VT, same as VF 2. hemodynamically stable VT; amiodarone, then lidocaine, then procainamide, if all fail then cardiovert 3. hemodynamically unstable VT; perform electrical cardioversion several times followed by medication-amiodarone, lidocaine, or procainamide |
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when is a patient considered hemodynamically instable |
chest pain dyspnea CHF hypotension confusion |
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normal EKG but no pulse |
PEA pulseless electrical activity due to low cardiac output |
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causes of PEA |
1. tamponade 2. tension pneumothorax 3. hypovolemia and hypoglycemia 4. massive pulmonary embolus (PE) 5. hypoxia, hypothermia, metabolic acidosis 6. potassium disorders, either high or low |
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signs of palpitation, dizziness or lightheadedness, exercise intolerance or dyspnea, embolic stroke |
atrial arrhythmias and most commonly atrial fibrillation |
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flutter vs fibrillation on ECG |
flutter is regular, fibrillation is irregular flutter usually goes back into sinus rhythm or deteriorates to fibrillation |
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treatment of Afib |
rate control and anticoagulants chronic (lasting >2days)- anticoagulant before synchronized cardioversion hemodynamically unstable (like that of VT) and acute- immediate synchronized cardioversion |
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treatment of Afib and flutter |
best initial therapy to control rate with bblockers, CCB (verapamil, diltiazem) or digoxin. when rate is <100bpm, give warfarin, dabigatran or rivaroxaban (use aspirin in low risk patients) use heparin in presence of current clot in atrium |
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when to use either warfarin, dabigatran rivaroxaban or aspirin |
when CHADScore is less than 1, use aspirin, if 2 or more use warfarin and others |
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management of palpitation is a healthy hemodynamically stable patient |
SVT; 160-180/min best initial step 1. Vagal maneuvers (carotid massage, valsava, drive reflex, ice immersion) 2. Adenosine if vagal maneuvers don't work 3. beta blockers (metoprolol), CCB (diltiazem), or digoxin if adenosine is not effective |
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most liekly diagnosis SVT alternating with ventriculae tachycardia SVT that gets worse after diltiazem or digoxin observing the delta wave on EKG |
WPW wolff-parkinson-white syndrome short PR<120 and delta waves most accurate test is cardiac electrophysiology (EP) tells you where the anatomic defect is Radiofrequency catheter ablation is curative use procainamide or amiodarone if also present arrhythmia |
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management of sinus bradycardia |
ECG to identify cause asymptomatic, do nothing symptomatic, give atropine as best initial or pacemaker as most effective, in 2nd (mobitz ii) and 3rd degree AV block even if asymptomatic symptomatic= hypoperfusion |
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treatment of Vtach in an MI patient |
angiography for angioplasty or bypass if already on MI medications. correct underlying cause of ischemia |
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test that shows recurrence of Vtach in MI |
echocardiography if EF is normal , risk is minimal MUGA-nuclear ventriculography is most accurate but after using Echo |
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chronic vTach without MI, and unknown etiologies (unprovoked Vtach |
implantable diefribillation |
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indication of EP |
to identify source of Vtach |
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clinical features of caustic ingestion |
features of chemical burn or liquefaction necrosis laryngeal damage; Hoarseness, stridor esophageal damage; dysphagia, odynophagia gastric damage; epigastric pain, bleeding (hemetemesis, retrosternal or epigastric pain, hyperventilation) presence or absence of oral injury |
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management of caustic ingestion
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secure airway, breathing, circulation decontamination; removal of contaminated clothing and visible chemicals; irrigate exposed skin CXR and AXR for perforation endoscopy within 24hrs in absence of severe resp. distress or perforation |
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when is charcoal contraindicated |
in lye (caustic ingestion- sodium or potassium hydroxide). lye causes immediate esophageal errosion and perofration. endoscopy is needed within 24hrs to examine the extent of burn and charcoal will obstruct the view, also emetics are CI |
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complications of caustic ingestion |
perforation upper airway compromise stricture/stenosis within 2-3 weeks ulcers cancer |
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signs of anti-histamine poisoning like diphenhydramine |
diphenhydramine has both anti-histamine and anti-cholinergic effects if taken in excess (confusion and drowsiness is anti-histamine), dilated pupils, blurred vision, urinary retention, and dry mucosa for anti-cholinergic treat with physiostigmine |
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nausea, vomiting, abdominal cramps, myalgias, althralgias, diarrhea, restlessness in an IV drug user |
opiod withdrawal, give methadone only inpatient and when primary disease is medical |
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signs of TCA overdose |
1. CNS-drowsiness, delirium, coma, seizures, resp. depression 2. CVS- sinus tachy, hypotension, prolonged QT/PR/QRS intervals, V-tach, V-fib 3. anti-cholinergic; dry mouth, blurred vision, dilated pupil, urinary retention, flushing and hyperthermia |
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management of TCA poisoning |
supllemental oxygen, intubation IV fluids activated charcoal for patients within 2 hours of ingestion (unless ileus present) IV sodium bicarbonate for QRS widening or Ventricular arrhythmia (by removing the depressant action of TCA on sodium channels of myocardium) |
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how does TCA cause cardiac toxicity |
by inhibiting fast sodium channels in His-Purkinja system and myocardium QRS interval >100msec an indication of sodium bicarbonate therapy by increasing the extracellular PH and sodium |
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effect of sodium bicarbonate on urine alkalinization |
to remove salicylate in aspirin overdose |
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when is sodium bicarbonate contraindicated |
in sepsis and lactic acidosis as it is associated with increased mortality |
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schizophrenic patient with elevated CK, fever, muscle rigidity and diaphoresis is what and treatment |
neuroleptic malignant syndrome due to any anti psychotic with dopamine antagonism treat with dantrolene then dopamine agonist-bromocriptine, amantadine |