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17 Cards in this Set
- Front
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Two drunk men come to the ED. One has visual disturbance, and there is hyperemia of the retina. The other has developed kidney stones. He has "envelope-shaped" cyrstals in his urine. Both have a metabolic acidosis with an increased anion gap.
What is the most likely diagnosis? |
1) The first patient who is drunk with visual disturbance and an abnormal funduscopic examination has methanol intoxication.
2) The second patient who is drunk with oxalate crystal in the urine has ethylene glycol intoxication. Oxalate crystals appear in the shape of envelopes. Both cause metabolic acidosis. |
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Two drunk men come to the ED. One has visual disturbance, and there is hyperemia of the retina. The other has developed kidney stones. He has " envelope-shaped" cyrstals in his urine. Both have a metabolic acidosis with an increased anion gap.
What is the best initial therapy? |
Fomepizole is the best initial therapy for ethylene glycol or methanol poisoning. Fomeprizole is considered superior to ethanol infusion, because it is not intoxicating. Definitive therapy is with dialysis to remove the substances.
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Two drunk men come to the ED. One has visual disturbance, and there is hyperemia of the retina. The other has developed kidney stones. He has " envelope-shaped" cyrstals in his urine. Both have a metabolic acidosis with an increased anion gap.
How does the best therapy work? |
Fomepizole inhibits alcohol dehydrogenase. This prevents the productoin of the toxic metabolite and gives time for dialysis to be effective.
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A 32 yo woman comes to the ED six hours after having ingested a bottle of 50 extra-strength (500 mg each) acetaminophen tablets.
What should you do first for this patient? |
The best initial therapy for an OD of acetaminophen is N-acetyl-cysteine (NAC) and charcoal. Giving NAC is more important than getting a specific level of acetaminophen when the patient clearly states she took a potentially harmful amount of acetaminophen.
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A 32 yo woman comes to the ED six hours after having ingested a bottle of 50 extra-strength (500 mg each) acetaminophen tablets.
How does this treatment work? |
NAC works by replacing the glutathione reductase that is depleted from the metabolites of acetaminophen. When glutathione reductase has been depleted, the liver cells start to necrose.
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A 32 yo woman comes to the ED six hours after having ingested a bottle of 50 extra-strength (500 mg each) acetaminophen tablets.
Can you use charcoal? |
Charcoal can be used at the same time as the NAC. Charcoal does not bind enough of the NAC to result in a clinically significant impairment of its effects.
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A 70 yo woman with a history of osteoarthritis comes to the ED because of SOB, tinnitus, and decreased hearing. Her blood gas is initially alkalotic but changes to a pH of 7.28 with a pCO2, of 23. Her serum bicarbonate is low, and the anion gap is increased.
What is the diagnosis? |
Aspirin toxicity presents with hyperventilation secondary to direct stimulation of the respiratory centers in the brain. In addition, aspirin toxicity can cause tinnitus, encephalopathy, and with severe toxicity pulmonary edema and hyperthermia. In early toxicity, there is respiratory alkalosis from direct stimulation of the brain stem. This is followed by metabolic acidosis, because aspirin poisons the mitochondria and you lose the aerobic metabolism of oxidative phosphorylation. Lactic acidosis accumulates from anaerobic glycolysis.
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A 70 yo woman with a history of osteoarthritis comes to the ED because of SOB, tinnitus, and decreased hearing. Her blood gas is initially alkalotic but changes to a pH of 7.28 with a pCO2, of 23. Her serum bicarbonate is low, and the anion gap is increased.
What is the best initial therapy? |
Bicarbonate is the best initial therapy for aspirin poisoning.
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A 70 yo woman with a history of osteoarthritis comes to the ED because of SOB, tinnitus, and decreased hearing. Her blood gas is initially alkalotic but changes to a pH of 7.28 with a pCO2, of 23. Her serum bicarbonate is low, and the anion gap is increased.
How does the therapy work? |
Bicarbonate will alkalinize the urine, resulting in increased excretion of aspirin at the kidney tubule.
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An alcoholic patient with a seizure disorder is admitted for drowsiness, dysarthria, and difficulty walking. She does not know which medication she is on for her seizures. On PE, you find ataxia and both horizontal and vertical nystagmus. The head CT is normal.
Which seizure medication is most likely to have caused these symptoms? |
Phenytoin toxicity is the agent most likely to cause drowsiness, ataxia, and nystagmus. The type of nystagmus correlates with the severity of the phenytoin toxicity. Mild toxicity leads to horizontal nystagmus. In fact, horizontal nystagmus may be present even at the upper end of the normal therapeutic level of phenytoin. Severe phenytoin toxicity results in vertical nystagmus.
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An alcoholic patient with a seizure disorder is admitted for drowsiness, dysarthria, and difficulty walking. She does not know which medication she is on for her seizures. On PE, you find ataxia and both horizontal and vertical nystagmus. The head CT is normal.
What is the best therapy? |
No specific therapy to reverse phenytoin toxicity.
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A man with a history of depression and an empty bottle of amitriptylene comes to the ED with obtundation, dry mouth, dizziness, flushing, and dilated pupils.
What is the most urgent step to take? |
An EKG is the most urgent step in the evaluation of tricyclic antidepressant overdose. The EKG will show prolongation or widening of the QRS.
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A man with a history of depression and an empty bottle of amitriptylene comes to the ED with obtundation, dry mouth, dizziness, flushing, and dilated pupils.
How is the patient most likely to die if treatment is unsuccessful? |
The most common causes of death from TCA overdoses are arrhythmias and seizures.
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A man with a history of depression and an empty bottle of amitriptylene comes to the ED with obtundation, dry mouth, dizziness, flushing, and dilated pupils.
What is the mechanism of death from TCAs? |
TCAs inhibit the fast sodium channels in the His-Purkinje system as well as the atrial and ventricular myocardium. This decreases conduction velocity, increases the duration of repolarization, and prolongs absolute refractory periods. This effect is similar to that of quinidine.
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A man with a history of depression and an empty bottle of amitryptylene comes to the ED with obtundation, dry mouth, dizziness, flushing, and dilated pupils.
What is the best initial therapy? |
Bicarbonate should be given if the QRS is prolonged above 100 milliseconds.
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A guard at Madison Square Garden is being evaluated after a nerve gas attack. He is found to be salivating, lacrimating, urinating, and defacating. In addition, he has respiratory distress and bradycardia.
What is the best initial therapy? |
Atropine is the best initial therapy for organophosphate poisoning. Atropine reverses the effect of the anti-cholinesterase inhibitor and the massive amount acetylcholine that accumulates. Organophosphates are absorbed through the skin. Further absorption is prevented by removing the patient's clothes and washing the patient.
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A guard at Madison Square Garden is being evaluated after a nerve gas attack. He is found to be salivating, lacrimating, urinating, and defacating. In addition, he has respiratory distress and bradycardia.
What is the specific antidote? |
Pralidoxime is the definitive treatment for reversing organophosphate toxicity. Pralidoxime reactivates acetylcholinesterase.
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