Toxicology Empa Tintinalli's 7Th Ed

Front 1

What is the first priority in assessment and management of the poisoned patient?

Back 1

Airway, Breathing, and Circulation
pg 1187

Front 2

What is in the coma cocktail and should it be considered early?

Back 2

O2, naloxone, glucose, and thiamine
simple, inexpensive, and little risk
pg 1187

Front 3

What is Naloxone (Narcan) and how does it work?

Back 3

competitive opioid antagonist; without intrinsic toxicity; competitively reverses effects of opioid and restores ventilations and mental status
pg 1187

Front 4

When should Naloxone be given?

Back 4

only a RR of <12 breaths/ min is useful predictor of response to Narcan
pg 1187

Front 5

What is the dose of Naloxone?

Back 5

bolus - 0.4-2.0mg IV; maintenance - 2/3rds arousal dose / 1hr
pg1187-1189

Front 6

What is the relative risk using Naloxone?

Back 6

too large a dose = opioid withdrawal sxs
pg 1187

Front 7

T/F: a full physical exam is required to examine the toxic patient

Back 7

True: to include searching clothing for hidden substances
pg 1188

Front 8

T/F: in emergency setting, the tox screening labs (urine/serum) significantly contributes to the evaluation of the pt

Back 8

False: vague labs, false positives, and sampling error
pg 1188

Front 9

Given examples of types of decontamination.

Back 9

Gross - undress, copious water
Ocular - flushing (1-2Ls per eye)
GI - emesis, gastric lavage, activated charcoal, whole bowel irrigation
Urine pH - sodium bicarb
Hemodialysis
pg 1189-1190

Front 10

How to determine tube size and length for orogastric lavage, kids and adults?

Back 10

measure OG tube from chin to xiphoid process, kids 22-24F; adults 36-40F
pg 1190

Front 11

Contraindications to OG lavage?

Back 11

pills larger than tube, nontoxic ingestions, caustic agents, airway compromise
pg 1190

Front 12

Benefits of this method include: decon gut noninvasively, rapid administration, safe, decreases absorption and increases elimination

Back 12

Activated Charcoal (AC)
pg 1190

Front 13

Activated Charcoal dose and time frame

Back 13

Dosing 10:1 (AC to drug amount) or 1gram/kg (whichever larger); given within 1hr most effective
pg1190

Front 14

Activated Charcoal contraindications?

Back 14

esophageal or gastric perforation suspected or needing endoscopy
pg 1190

Front 15

Substances that poorly interact with activated charcoal.

Back 15

metals (iron, lithium, lead), hydrocarbons (methane, propane, parafin wax), and toxic alcohols
pg1191

Front 16

These meds are often given with AC to decreases transit time for the passage of gastric contents.

Back 16

Cathartics - Sorbitol 70% (1g/kg) or MgCitrate 10% (250mL adults and 4mL/kg kids)
pg1192

Front 17

This method of decon instills large volumes of polyethylene glycol in osmotically balanced soln and produces rapid catharsis by mechanically forcing contents through bowel.

Back 17

Whole bowel irrigation

Front 18

Dose (adults/kids) and considerations for Whole Bowel Irrigation

Back 18

Polyethylene Gylcol - 1L/hr (adults) and - 0.5L/hr (kids); consider Zofran co-administration IV for N/V side effects
pg1192

Front 19

T/F: Urinary alkalinization is typically used to induce high urinary pHs to promote acidic toxins excretions. Goal of urinary pHs is 8.0-9.0.

Back 19

False: Goal is pH 7.5-8.5

Front 20

T/F: Pronounced hyperkalemia typically occurs with urinary alkalinization and requires calcium gluconate co-administration for control

Back 20

False: Hypokalemia should be corrected to avoid hydrogen ion excretion and potassium resorption; acidifying the urine

Front 21

How do you alkalinize the urine?

Back 21

Sodium Bicarb 1-2mEq/kg IV bolus or 3-4mEq/kg/Hr
serum should NOT rise about 7.5-7.55
pg1192

Front 22

Hemodialysis indicated when and for what?

Back 22

When - drugs have systemically absorbed, can't be absorbed by AC, and to remove parent compound and toxic metabolites.
What - salicylates, toxic alcohols, Lithium, Theophylline, Carbamazepine
pg 1193

Front 23

Opioids - examples, findings, interventions

Back 23

Heroin, Morphine, Oxycodone;
CNS and Resp depress, miosis, bradycardia, hypothermia;
Ventilation and Naloxone (0.4-2.0mg IV)

Front 24

Sympathomimetics - examples, findings, interventions

Back 24

Cocaine, Amphetamines;
Agitation, mydriasis, diaphoresis, tachycard, HTN, hyperthermia;
Cooling, benzos, hydrate

Front 25

Cholinergic - examples, findings, interventions

Back 25

Organophosphates & Carbamate insecticides; Killer B's DUMBBBELS;
ABC's, ventilate, atropine (1mg IV repeat q 5min until desired effects) , pralidoxime (1-2g/5mins, 500mg/h maintenance)

Front 26

DUMBBBELS stands for what?

Back 26

D- defecation, U -urination, M - miosis, B -bradycardia, B -bronchorhea, B - bronchospasm, E -emesis, L - Lacrimation, S - salivation

Front 27

Anticholinergics - examples, findings, interventions

Back 27

Scopolamine, Atropine;
AMS, mydriasis, dry skin and mucous membranes, red, urinary retention, decreased BS, hot, rhabdo, seizures;
Benzos, cooling, supportive, Physostigmine (0.5-2.0mg/ 5min IV)

Front 28

Salicylates - examples, findings, interventions

Back 28

ASA, Oil of Wintergreen;
AMS, respiratory alkalosis, metabolic acidosis, tinnitus, hyperpnea, tachycardia, diaphoretic, N/V;
AC, Sodium Bicarb (w/ K+), hemodialysis

Front 29

Sedatives/ Hypnotics - examples, findings, interventions

Back 29

Barbiturates, Benzos;
AMS, Depressed LOC, slurred speach, ataxia, bradycardia;
ventilatory support

Front 30

Hypoglycemia - examples, findings, interventions

Back 30

Sulfonylureas, Insulin;
AMS, diaphoresis, tachycardia, hypertension, seizures, slurred speech;
Glucose IV soln, oral feedings, octreotide 50-100mcg SC q 6hrs (insulin overdose)

Front 31

Hallucinogenic - examples, findings, interventions

Back 31

Mescline, Phencyclidine;
Hallucinations, dysphoria, anxiety, mydriasis, nausea, tachy, agitated;
generally supportive

Front 32

Serotonin - examples, findings, interventions

Back 32

SSRIs (Celexa, Prozac, Paxil, Zoloft), TCAs, MOA-Is SSNRI (Effexor, Cymbalta);
AMS, increased muscle tone, hyperreflexia, hyperthermia, tremors;
Cooling, Benzos, supportive

Front 33

Extrapyramidal - examples, findings, interventions

Back 33

Haloperidol, Phenothiazines (Phenergan and Compazine), Resperidone;
dystonia, torticollis, muscle rigidty;
Benzos, Benadryl

Front 34

T/F: TCA overdoses: Life threatening symptoms usually occur with ingestions > 20mg/kg in adults and fatalities with ingestions >2grams.

Back 34

False: Life threatening symptoms >10mg/kg and fatal >1gram.
pg1194

Front 35

What is the most common symptom and most common dysrhythmia with TCA overdose?

Back 35

most common symtoms - AMS
dysrhythmia - sinus tachycardia 70% of pts
pg 1194

Front 36

What time frame are most serious toxic symptoms going to appear by in TCA overdoses?

Back 36

6 hrs; sxs - coma, cardiac conduction delays, SVT, HoTn, resp depr., PVC, seizures
pg1194

Front 37

Cardiac conduction delays result from sodium channel blockade resulting in prolonged QT intervals (>100milliseconds) in TCAs. What is the txmt?

Back 37

give AC (w/ in 1 hr), Sodium Bicarb (1-2mEq/kg) repeated until improvement or serum pH is around 7.5, and admission to ICU; Benzo's (ativan or valium) used if seizures present pg 1195

Front 38

TCA overdose: seizures resistant to Benzo's require?

Back 38

ET intubation and Phenobarbital 15mg/kg (SE include HoTn)
pg 1198

Front 39

How should hypotension, in TCA overdoses, be treated?

Back 39

cystalloids increments of 10mL/kg bolus; if not responsive to fluid and bicarb consider vasopressors (norepinepherine 1-30mcg/min)
pg 1198

Front 40

What is a "lipid sink" therapy in TCA txmt?

Back 40

IV Lipid emulsion therapy - due to highly lipophilic / soluble make up of TCAs, binds TCAs for elimination
lipid emulsion 100mL/ 1 min IV

Front 41

The drug most commonly overdosed on in the SSRI category is and what is the half life?

Back 41

Prozac (Fluoxetine) and 36hr half life. Pt's should be monitored for 24hrs
pg 1201

Front 42

T/F: SSRI's and SSNRI's cause sympathetic nervous system stimulation via inhibition of norepi reuptake.

Back 42

True
pg 1202

Front 43

What 3 symptoms define Serotonin Syndrome? Think the Three A's

Back 43

AMS (confusion, agitation),
Autonomic NS (hyperthermia, HR, RR),
Altered Neuromuscular (myoclonus, rigidity, hyperreflexia)
pg 1203

Front 44

Most common finding in Serotonin Syndrome?

Back 44

Myoclonus - 57% - important b/c rarely seen in other conditions
pg 1203

Front 45

Treatment of Serotonin Syndrome

Back 45

O2, IV, AC (w/in 1hr), OG lavage, wait & watch...
> 24hrs try Cyproheptadine 4-8mg PO

Front 46

What is a common OTC herbal that produces MAO-I's toxicity?

Back 46

St. Johns Wort

Front 47

How do MAO-I's ("-gilines") work / thus producing toxicity?

Back 47

MAO-I's inhibit oxidative deamination of norepi, epi, dopamine, serotonin, and tyramine (structurally similiar to amphetamines)
increase synaptic availability and tyramine - releases stores of epi, norepi presynaptically
pg 1204

Front 48

T/F: Toxic symptoms of MAO-I's typically appear within 6 hrs

Back 48

False: 6-12hrs sxs appear, with delays up to 24hrs
pg 1205

Front 49

What is the typical presentation of MAO-I overdose?

Back 49

None. There is no typical and clinical dx based solely on hx of taking the drug.

pg 1206

Front 50

This type of overdose is very similar to opioid overdose except for tachycardia?

Back 50

Antipyschotics

Front 51

What is the Occult Triad of Death, referring to Antipsych overdose? (Bebarta's lecture)

Back 51

Pyrexia (fever), Rhabdo, and Acidosis

Front 52

Describe antipsych symptoms.

Back 52

opioid like - lethargy, AMS, resp depr., and urinary retention
anticholinergic like - decr. BS, dry skin and mucous membranes, tachycardia, hyperthermia, urinary retention
pg 1210

Front 53

Treatment of Antipsyc overdoses?

Back 53

IV, O2, monitor, Naloxone and thiamine, benzo's (is seizures), fluids and pressors for HoTn, mag for torsades
pg 1210-1211

Front 54

T/F: Isopropanol is twice as potent as ethanol in causing CNS depression and is 2-4x longer lasting.

Back 54

True
pg 1224

Front 55

What is the hallmark of isopropanol toxicity?

Back 55

Ketosis and an osmolar gap WITHOUT acidosis

Front 56

What is a striking symptom related to isopropanol toxicity?

Back 56

Gastric irritation leading to hemorrhagic gastritis with significant upper GI bleeding.
pg 1225

Front 57

T/F: Treatment of choice for toxic alcohols is timely administration of Activated Charcoal.

Back 57

False: AC does not bind to toxic alcohols.

pg 1225

Front 58

Which is more toxic in methanol and ethylene glycol poisonings, the parent compound or metabolite?

Back 58

Metabolites. Once the liver metabolizes these compounds they cause acidosis and end-organ damage
pg 1225

Front 59

What is a differentiating feature of methanol poisoning compared to other toxic alcohols?

Back 59

visual changes (snowy or blurred vision) - formic acid (toxic metabolite) deposits in the retina and optic nerve tissue
pg 1226

Front 60

What is the treatment for methanol overdose?

Back 60

ABC's and preventing metabolism of alcohol to metabolite
Fomepizole 15mg/kg IV loading dose over 30mins, 10mg/kg IV q 12hrs

Front 61

What is the toxic metabolite of Ethylene Glycol (antifreeze)?

Back 61

Glycolic Acid
pg 1226

Front 62

Ethylene Glycol symptoms classically present with?

Back 62

CNS depression, metabolic acidosis, and renal failure
other sxs: ab pain, N/V, tachycardia, tachypnea (compensate for meta. acidosis)
pg 1227

Front 63

What are some tests to consider in Toxic Alcohol poisonings?

Back 63

ABG, CMP, Serum Osmolarity, CK, Ethanol level, Lactate, EKG, UA and CXR
pg 1227

Front 64

What is the dose of ethanol for IV management of toxic alcohol overdoses?

Back 64

Ethanol 800mg/kg loading dose
Maintenance is 100mg/kg/hr
pg 1229

Front 65

What are some indications for Urgent Hemodialysis after Ethylene or Methanol ingestion?

Back 65

refractory metabolic acidosis
visual abnormalities
renal insufficiency
electrolyte abnormality despite intervention
deteriorating VS
pg 1229

Front 66

What are some of the effects of mu receptor stimulation by opioids (coedine, morphine, oxcodone, tramadol, fentanyl)?

Back 66

analgesia, sedation, euphoria, cough suppression, miosis, resp. depres, and decreased GI motility.
pg 1230

Front 67

T/F: the respiratory depression associated w/ opioid overdose results in hyperpnea (deep breathes)

Back 67

False: results in small, shallow breathes leading to hypercarbnia, hypoxia and cyanosis
pg 1231

Front 68

This triad was found to have a 92% sensitivity for opioid overdose.

Back 68

RR < 12b/min, miosis, and evidence of opioid use (drug paraphernalia, tourniqet, bystander)
pg 1231

Front 69

Naloxone treatment differs how in chronic opioid vs non-opioid users overdose?

Back 69

Dose is much lower in chronic users, 0.05mg IV vs 0.4-2mg for non-chronic users.
pg 1233

Front 70

Opioid withdrawal sxs include and can be treated with?

Back 70

anxiety, yawning, lacrimation, rhinorrhea, myalgias, mydriasis
txmt: clonidine 5mcg/kg PO or atarax 50-100mg PO q 6hrs
pg 1234

Front 71

How does cocaine work as a anesthetic and a CNS stimulant?

Back 71

1) inhibits nerve conduction by blocking fast sodium channels
2) blocks reuptake of neurotransmitters presynaptically
(incr. sympathetic response - tachy, mydriasis, HTN, diaphoresis)
pg 1234

Front 72

Amphetamines (methylpenidate, ephedrine, pseudophedrine) mechanism of action?
(3 ways)

Back 72

1) enhance release of catecholamines
2) block reuptake of catecholamines
3) directly stimulate catecholamine receptors
pg 1235

Front 73

T/F: Cocaine is a potent vasodilator, often leading to hypotension and LOC.

Back 73

False - potent vasoconstrictor leading to chest pain, acute coronary vasospasm, intestinal ischemia, and spontaneous abortion in pregos
pg 1236

Front 74

Describe the symptoms of the sympathomimetic toxidrome.

Back 74

agitation, mydriasis, diaphoresis, tachycardia, tachypnea, HTN, hyperthermia,
other sxs: seizure, intracranial hemorrhage, chest pain pg 1236

Front 75

Treatment of sympathomimetic overdose.

Back 75

-VS monitoring, IV (fluids -rhabdo), O2
-Benzo's (sedation)- Lorazepam 2mg IV
-Cooling
Nitroprusside 0.3mcg/kg/min - HTN
Detox and Social Services
pg 1237

Front 76

Young woman with N/V, tinnitus, hearing loss, sweating, hyperventilation, metabolic acidosis and resp. alkalosis is likely what toxidrome?

Back 76

Salicylates (ASA)
pg 1244

Front 77

T/F: When diagnosing ASA intoxication, using the Done monogram is helpful for determining when to treat.

Back 77

False: use of the Done monogram is no longer recommended pg 1245
use sxs, acid-base status, serum concentration

Front 78

T/F: It is key to wait for a 4hr serum salicylate level for accuracy.

Back 78

False: immediate serum Salicylate level should be drawn with seriel levels q 1-2hrs until concentrations decline.
pg 1245

Front 79

Treatment of Salicylate overdose is?

Back 79

ABC's, correct volume and electrolyte depletion, GI decon (OG lavage and AC), Urinary Alkalinization, Hemodialysis (last line)

Front 80

Indications for hemodialysis during Salicylate toxicity.

Back 80

- vent needed
- failure of alkalinizing urine to help
- renal insufficiency
- AMS
- severe acid-base disturbance
pg 1246

Front 81

Advantages of hemodialysis in Salicylate toxicity.

Back 81

- corrects acid-base disturbance
- corrects electrolytes
- rapidly reduces salicylates in body

Front 82

How does hepatic necrosis occur in Acetaminophen overdose?

Back 82

Hepatic metabolism is saturated, depleting glutathione levels. Glutathione can no longer bind NAPQI and thus hepatic cells are bound and killed. pg 1247

Front 83

What are the clinical sxs and relevant labs of Stage 1 APAP toxicity?

Back 83

First 24hrs - Anorexia, N/V, Malaise
Labs - Hypokalemia
pg 1248

Front 84

What are the clinical sxs and relevant labs of Stage 2 APAP toxicity?

Back 84

Days 2-3 - Ab pain, Hepatic Tenderness
Labs - Elevated transaminases, bilirubin, and prolonged PT
pg 1248

Front 85

What are the clinical sxs and relevant labs of Stage 3 APAP toxicity?

Back 85

Days 3-4 - N/V, Jaundice, Encephalopathy
Labs - Liver Failure, Met. Acidosis, Coagulopathy, Renal failure, Pancreatitis
pg 1248

Front 86

What are the clinical sxs and relevant labs of Stage 4 APAP toxicity?

Back 86

Day 5+ - Clinical improvement or end organ failure (death)
Labs - improvement or deterioration
pg 1248

Front 87

Toxic doses of APAP (adult)?

Back 87

1) > 10grams or 200mg/kg (single ingestion or 24hr period)
2) >6grams or 150mg/kg x 2 days
pg 1248

Front 88

What is the Rumack-Matthew monogram 4hr level for treatment decisions?

Back 88

150mcg/mL
pg 1249

Front 89

T/F: Naloxone 140mg/kg (Oral) or 150mg/kg (IV) is the treatment of choice for APAP overdoses.

Back 89

False: NAC (N-acetylcysteine) 140mg/kg PO or 150mg/kg IV
Oral = bad taste - give w/ Zofran
pg 1249

Front 90

N-acetylcysteine if given within __ hrs is nearly 100% effective in preventing heptotoxicity.

Back 90

8hrs
pg 1249

Front 91

How many Oral NAC doses must be given (including loading dose)?

Back 91

Loading dose 140mg/kg
Maintenance dose 70mg/kg q 4 hrs for 17 doses
= 18 total doses
pg 1250

Front 92

How long does IV NAC treatment last?

Back 92

20hrs - IV
Loading -150mg/kg (in 200mL D5) over 1hr
Maintenance - 50mg/kg (in 500mL D5) over 4hrs, then
100mg/kg (in 1000mL D5) over 16hrs pg 1250

Front 93

T/F: Due to APAP's rapid absorption Gastric Decon is not useful.

Back 93

False: if within 4hrs aggressive AC should be tried and 4hr APAP level ordered

Front 94

If btwn 4-24hrs of APAP overdose when should NAC be given?

Back 94

if < 8hrs and a level is back, then plot and treat with NAC or treat symptomatically
if level not back by 8hrs - treat immediately
pg 1251

Front 95

T/F: Chronic NSAID USE results in greater morbidity and mortality than acute OVERDOSE.

Back 95

True. (Renal insufficiency and GI Bleeds)
pg 1254

Front 96

T/F: most NSAID overdose symptoms begin within 2hrs of ingestion.

Back 96

False: 4hrs
pg 1254

Front 97

Describe NSAID overdose symtpoms.

Back 97

GI - Ab pain, N/V
CNS - nystagmus, HA, AMS, seizures
Cardiac - HoTn, Shock, Bradycardia
Electrolyte - hyperkalemia, hypocalcemia, hypomagnesemia pg 1254

Front 98

T/F: Treatment for NSAID overdose is largely supportive.

Back 98

True: support ABCs and replenish electrolytes
pg 1256

Front 99

How does Digitalis (Digozxin) work in the heart?

Back 99

Inhibits sodium-potassium ATPase pumps, leading to intracellular build up of Ca+, slows nerve conduction but increases contractility.
pg 1261

Front 100

Due to a narrow therapeutic window (0.5-2.0ng/mL), Digoxin toxicity can be easy. What are some clinical features?

Back 100

syncope, dysrhythmias, hyperkalemia, AMS, N/V, lethargy, visual effects (Halos), ST depression on EKG
pg 1261

Front 101

T/F: Continuous cardiac monitoring is required for asymptomatic Digitalis overdoses.

Back 101

True: Continuous cardiac monitoring, IV access, and frequent reevals should be provided for ANY pt with potentially toxic Digoxin ingestion.
pg 1263

Front 102

What is the preferred antiarrhythmic for the treatment of ventricular dysrhythmias due to Digoxin toxicity?

Back 102

Fosphenytoin 15mg PE/kg (prodrug of phenytoin) - accelerates the AV node conduction
pg 1263

Front 103

T/F: GI Decon to include AC, OG lavage and cathartics have utility in early ingestion of digoxin.

Back 103

False: AC -YES
OG lavage - linked to asystole due to vagal stimulation
Cathartics and hemodialysis - no role
pg 1263

Front 104

Digbind (Digoxin-specific Fab antibody) formula for use:

Back 104

Number of vials needed = [serum dig level x pt weight] / 100
1 vial = 38-40mgs; 5-12 vials commonly used
pg 1264

Front 105

What is the hallmark of BB toxicity?

Back 105

Bradycardia and Shock
pg 1265

Front 106

Why is Sotol different from other BBs?

Back 106

ability to block potassium channels and prolong QT interval
pg 1265

Front 107

Initial evaluation of BB toxicity includes EKG, cardiac US, CMP, VBG, and acid base status. What are the treatment options?

Back 107

fluid, glucagon (1st line), Beta agonists, insulin, calcium, phosphodiesterase inhibitors
pg 1267

Front 108

What is the dose of glucagon and how often is it given?

Back 108

Glucagon 0.05-0.15mg/kg and repeated as often as necessary. Effects usually seen in 1-2minutes
pg 1267

Front 109

What Beta Agonists are used for BB overdose?

Back 109

Norepi, Epi, Dopamine.
Norepi most effective due to ability to increase HR and BP.
pg 1267

Front 110

How does insulin correct BB toxicity?

Back 110

Insulin forces glucose in to the heart cells to use in times of stress. Cardiac cells typically use fatty acids but resort to glucose in stress.
pg 1267

Front 111

How is insulin given and what is the dose in BB toxicity?

Back 111

Insulin 1 unit/kg IV bolus (with 0.5g/kg of glucose)
Maintenance 0.5 unit/kg/hr (maintain euglycemia)

Front 112

T/F: Atropine is a effective treatment in BB toxic symptoms of bradycardia and hypotension.

Back 112

False: Atropine is a muscarinic blocker (opposes Vagus nerve conduction) and is likely to do the pt harm. BB toxicity is not a problem of Vagus nerve conduction.
pg 1268

Front 113

Common triad sxs with CCB toxicity?

Back 113

Hypotension, bradycardia, and AV Block.
pg 1270

Front 114

T/F: Hypoglycemia is often noted after CCB overdose.

Back 114

False: Pancreatic beta islet cells are reliant on calcium in order to secrete insulin.
pg 1270

Front 115

Treatment of choice for CCB toxicity is?

Back 115

Calcium! Calcium Chloride is preferred over Calcium Gluconate but requires central access.
pg 1271

Front 116

At what serum level due iron toxicity symptoms develop and what are they?

Back 116

20-60mg/kg - moderate (N/V/D, ab pain)
> 60mg/kg (shock, met acidosis, coagulopathy, hepatic failure, cardiac failure
pg 1284

Front 117

Initial Iron levels at the 2hr mark are <300mcg/dL and no symptoms seen, what is next step?

Back 117

Watch and wait for 6 hrs. Measure 4hr Iron level and if remains asymptomatic and <500mcg/dL = discharge
symptoms and > 500mcg/dL = UA and Deferoxamine 1000mg IV (5mg/kg/hr) pg 1286

Front 118

What is Deferoxamine?

Back 118

It is a chelating agent that binds iron and is excreted through the urine.
pg 1286

Front 119

Cholinergic toxidromes are related to what ingestions/ exposures and present how?

Back 119

Pesticides (Organophosphates and Carbamates)
DUMBBBELS - diarrhea, urination, miosis, bradycardia, bronchospasm, bronchorrhea, emesis, lacrimation, salivation
pg 1299

Front 120

T/F: Atropine is indicated for bradycardia related to pesticide toxicity but not tachycardia.

Back 120

False: Indicated for BOTH brady and tachy since tachy is likely due to bronchospasm and/ or bronchorrhea and can help with both.
pg 1300

Front 121

T/F: Atropine 1mg IV is given every 5min for three attempts in cholinergic toxicity.

Back 121

False: Atropine 1mg IV (adults) 0.04mg IV (kids) repeated q 5min until symptoms resolve. large amounts needed.
pg 1300

Front 122

Pralidoxime dose is what in adults and kids and works how?

Back 122

Pralidoxime 1-2grams IV (adults) and 20-40mg IV (kids)
Displaces pesticides from acetylchoinesterase receptor, reactivating the enzyme.
pg 1300

Front 123

How do the anticholinergic (benadryl, anti-histamines, atropine, TCAs) substances work and what are the symptoms?

Back 123

inhibit acetylcholine by binding to muscarinic and nicotinic receptors
Fever, dry skin and membranes, flushing, agitated, mydriasis, tachy, urine retention
pg 1306

Front 124

Treatment of Anticholinergic toxicity?

Back 124

GI Decon (AC), Sedation (Benzo's- reduce risk of hyperthermia and rhabdo), Sodium Bicarb (for wide complex tachys), and Physostigmine 0.5-2.0mg IV (last resort - call toxicologist)
pg 1307

Front 125

What will kill the anticholinergic overdose pt?

Back 125

Seizures - treat with Ativan, fluids, supportive treatments
Bebarta Lecture

Front 126

What are some drugs commonly found to produce Methemoglobinemias?

Back 126

Antimalarials, Benzocaine, Sodium Nitrite (cyanide kit)
pg 1327

Front 127

Clinical symptoms of Methemoglobinemias?

Back 127

levels btwn 20-30% - HA, weakness, CYANOSIS, anxiety, tachypnea, an sinus tach
pg 1328

Front 128

T/F: Pulse oximetry routinely reads levels of 60-70% O2 sat with a Methemoglobinemia level of 30-40%.

Back 128

False: Pulse ox reads abnormally high, 80-85%.
pg 1329

Front 129

What is the treatment in a symptomatic pt with a methemoglobemia level >25%?

Back 129

Methylene Blue 1-2mg/kg
acts by increasing enzymatic breakdown of methemoglobin.
pg 1329

Front 130

How do you treat ETOH or Benzo withdrawal?

Back 130

give benzo's (2,4,6,8mg) and be ready to intubate

Bebarta lecture

Front 131

Do all Serotonin Syndromes have to have fever?

Back 131

No, not that common.

Bebarta Lecture

Front 132

What is the most likely bone to fracture in the orbital?

Back 132

Ethmoid bone (Lamina Papyracea - thinnest portion of ethmoid)
pg 1517

Front 133

What should your eye exam include?

Back 133

visual acuity (VS of the eye), confrontational visual fields, EOMs, Pupil reaction, anatomic features, IOP, and fundiscopic exam
pg 1517

Front 134

Visual acuity takes precedence in vision threatening disorders, except?

Back 134

chemical burns - irrigate first
pg 1518

Front 135

Which cranial nerve innervates the superior oblique muscle?

Back 135

CN IV
pg 1522

Front 136

Which cranial nerve innervates the lateral rectus muslce?

Back 136

CN VI
pg 1522

Front 137

Which cranial nerve innervates all the extraocular muscles, except the lateral rectus and superior oblique?

Back 137

CN III
pg 1522

Front 138

Describe a positive Afferent Pupillary Defect (APD) and what does it indicate?

Back 138

APD is when the pupil dilates in response to light.
Indicates a optic nerve disorder. pg 1522-23

Front 139

Teardrop-shaped pupil related to blunt or penetrating trauma is likely a _____.

Back 139

Prolapse of the iris - iris ruptures through cornea
pg 1522

Front 140

T/F: The contact lens can be left in for the fluorescein stain assessing for cornea damage.

Back 140

False: Always remove the contact lenses, as fluorescein will permanently stain the lenses. pg 1524

Front 141

What is the normal intraocular pressure and when is IOP measurement contraindicated?

Back 141

10-20mmHg and suspected ruptured globe
pg 1527

Front 142

Pt with excessive tearing, fever, erythema, edema, warmth, and TTP of the lids and periorbital soft tissues is likely?

Back 142

Orbital or Periorbital Cellulitis.
pg 1528

Front 143

What is the best way to distinguish btwn periorbital and orbital cellulitis and what imaging is needed?

Back 143

full painless ocular motility = periorbital (preseptal)
pain when moving eyes = orbital (postseptal)
CT w/ contrast pg 1528

Front 144

Treatment for orbital cellulitis includes pain medication, warm compresses, and what type of antibiotics?

Back 144

2nd or 3rd Gen Cephalosporin
(Ceftin 750mg IV q 8h or Rocephin 1-2g IV q 12hrs)
PCN allergies -Levaquin 750mg IV q 24hr & Clindamycin 4800mg IV q 24hrs pg 1530

Front 145

Common bacterial source for styes, blepharitis, and baterial conjunctivitis is ?

Back 145

Staphylococcus
pg 1530

Front 146

Painful, burning, and vesicular erruption on the upper eyelids and tip of the nose; blurred vision and photophobia is likely ___ and treated w/ ___.

Back 146

Herpes Zoster Ophthalmicus and treated w/ oral antivirals and topical ophthalmalic steroids (prednisolone 1% one drop q 4hrs) pg 1533

Front 147

Extended-wear and soft contact lens use can lead to this common cause of impaired vision and blindness worldwide.

Back 147

Corneal Ulcer
pg 1533

Front 148

What bacteria is commonly associated with contact induced corneal ulcers and how do you treat?

Back 148

Psuedomonas
Topical Abx - ciprofloxacin 1 gtt q 1hr, emergency ophtho consult, * no patching! pg 1533

Front 149

What does a positive Seidel test indicate?

Back 149

Fluorescein green aqueous fluid leaking through a full thickness corneal wound.
pg 1526

Front 150

T/F: all blowout fractures require emergent ophthalmology consults in the ER.

Back 150

False: blowout fractures with normal eye exam in the ED can be sent for outpatient referral.
pg 1539

Front 151

When should the IOP be measured for a ruptured globe?

Back 151

Never, due to the possibility of extruding the intraocular contents
pg 1541

Front 152

Which ocular chemical injury is more common and serious?

Back 152

Alkali (found in many household cleaners) and cause liquefaction necrosis
pg 1542

Front 153

What is the treatment for acute closed angle glaucoma?

Back 153

Topical BB (timolol 0.5% 1 gtt)
Mannitol 1-2g/kg IV
Acetazolamide 500mg IV
Top Pilocarpine 1-2% 1 gtt
pg 1544

Front 154

Sudden monocular, painless vision loss with a cherry red spot on exam is _____.

Back 154

Central Retinal Artery Occlusion
pg 1544-45

Front 155

Vague blurring, painless monocular vision loss with diffuse retinal hemorrhage ("blood and thunder") on exam is _____.

Back 155

Central Retinal Vein Occlusion
pg 1545

Front 156

55yo WF presents with 2 week onset of flashing lights in the right eye. Loss of peripheral vision. what is likely cause?

Back 156

Retinal detachment
pg 1545

Front 157

Ptosis, HA, and pupillary dilation in one side is concerning for what disease?

Back 157

Posterior Communicating Artery Aneurysm
need control of BP, neuroimaging, and neurosurg
pg 1546

Front 158

Pt c/o N/V, HAs, blurred vision. Increased ICP, papilledema and normal CSF on LP is _____.

Back 158

Pseudotumor Cerebri
pg 1547

Front 159

Most common causes of sudden hearing loss (loss occurring < 3 days)?

Back 159

Viral - Mumps
Meds - Loop diuretics, ASA, Neomycin, Polymyxin B
Trauma
pg 1552

Front 160

Most common causes of Otitis Externa?

Back 160

Pseudomonas, Enterobacteriaceae, Proteus, and Staph
pg 1552

Front 161

Most common cause of Otitis Media?

Back 161

Viral 70%
Bacterial - Strep, Haemophilus, Moraxella
pg 1553

Front 162

12yo M c/o 1 week right ear infection. Mother says he has fever and the pain is keeping him up at night. Exam reveals otitis media with postauricular swelling and tenderness. What is next step?

Back 162

Mastoiditis: CT imaging for extent of bony involvement, Admission for Vancomycin IV, tympanocentesis, myringotomy. pg 1554

Front 163

High school wrestler presents with painful auricular swelling after a match. What is treatment?

Back 163

Auricular Hematoma: aspiration of clot and fluid and pressure for several days.
pg 1556

Front 164

Where do the majority of sialoliths occur?

Back 164

Submandibular gland 80%
pg 1561

Front 165

Pt c/o left sided facial swelling, pain, erythemia, and trismus following dental extraction of tooth #18. What is the concern for and treatment?

Back 165

Concern for Masicator Space infection
Contrast CT
Clindamycin IV and ENT consult
pg 1562

Front 166

T/F: Posterior dislocation is the most common mandible dislocation.

Back 166

False: Anterior dislocation
pg 1562

Front 167

How do you diagnose posterior epistaxis in the ED?

Back 167

Once measures to control anterior epistaxis have failed
pg 1565

Front 168

Name a few ways to control epistaxis in the ED.

Back 168

Direct Nasal Pressure
Cautery (Silver Nitrate)
Thrombogenic Foams (Surgicel)
Ant. Nasal Packing (balloons, nasal tampon, or packing)
pg 1565-66

Front 169

What is the main priority for the treatment of nasal fractures?

Back 169

Exclusion of other associated traumatic injuries (Le Forte) and nasal septal hematoms.
pg 1569

Front 170

Why do nasal septal hematomas require urgent incision and drainage?

Back 170

Avoid pressure necrosis and development of abcesses.
pg 1569

Front 171

Postextraction exquisite oral pain typically relates to Dry Socket. How do you treat this?

Back 171

Dental radiographs (retained root tip or FB)
Irrigation
Topical anesthetic
Packing gauze (oil of cloves)
Pen VK 500mg PO q 6h
pg 1575

Front 172

Triad of oral pain, ulcerated or "punched out" interdental papillae, and gingival bleeding is ______?

Back 172

ANUG - Acute Necrotizing Ulcerative Gingivitis
pg 1576

Front 173

Treat for ANUG includes?

Back 173

Chlorhexadine 0.1% oral rinses BID, Metronidazole 500mg PO TID and dental referral
pg 1576

Front 174

Most important predisposing factor in ANUG is ____?

Back 174

HIV infection
pg 1576

Front 175

What is the most common site involved in oral cancer?

Back 175

Posterolateral boarder of tongue 50%
pg 1578

Front 176

T/F: Biopsy is required for all lesions of the tongue to r/o cancer.

Back 176

False: lesions that CANNOT be scrapped off are concerning for leukoplakia
pg 1578

Front 177

Describe the classification of tooth fractures.

Back 177

Ellis Class I - enamel portion
Ellis Class II- involve dentin
Ellis Class III- exosed pulp
pg 1580

Front 178

Which Ellis classifications require dental cement?

Back 178

Ellis Classes II and III - pulp should be sealed to avoid infection.
pg 1580

Front 179

What is the timeframe for tooth reimplantation?

Back 179

2-3hrs

Front 180

What media aer acceptable for transport of an avulsed tooth?

Back 180

saline, milk, saliva, Hank's balanced salt soln.
pg 1581

Front 181

T/F: Before reimplantation of a tooth the provider should irrigate and scrub the tooth clean from crown to apex to avoid contamination.

Back 181

False: only handle the crown, irrigate, and do NOT scrub root (has peridontal fibers)
pg 1581

Front 182

What is the key to reimplantation of PRIMARY teeth?

Back 182

Never reimplant!
pg 1582

Front 183

What are the Centor criteria for GABHS pharyngitis?

Back 183

1) tonsillar exudates, 2) ant cervical lymphadenopathy, 3) no cough, and 4) fever
pg 1583

Front 184

Based on the Centor criteria, when do you treat pharyngitis with antibiotics?

Back 184

- 3-4 of criteria met
- 2,3 or 4 criteria w/ positve Rapid Strep
pg 1584

Front 185

Treat of choice for GABHS pharyngitis?

Back 185

-Pen VK 500mg q 6h x 10 days or Clindamycin for PCN allergies
+/- single dose IM dexamethasone
pg 1584

Front 186

What is the major risk factor when performing a I&D or needle aspiration of a peritonsillar abscess?

Back 186

puncturing the internal carotid, 1cm being posterior edge
pg 1585

Front 187

Pt with worsening sxs of drooling, dysphagia, and distress, especially supine, is concerning for?

Back 187

Epiglottitis
pg 1585

Front 188

T/F: CT scan is the perferred imaging modality for diagnosis of epiglottitis.

Back 188

False: lateral neck plain films
CT in supine position will worsen symptoms
pg 1585

Front 189

This dz is polymicrobial, can extend in to the mediastinum from the neck, and presents with sore throat, fever, torticollis, and dysphagia.

Back 189

Retropharyngeal Abscess
pg 1586

Front 190

How is Retropharyngeal abscess diagnosis (imaging) and treated?

Back 190

Contrast CT of neck - gold standard
- immediate ENT consult, IV fluids, Rocephin 2grams IV
pg 1586

Front 191

T/F: Adults >40yo, up to 75% of lateral neck masses present for > 6 weeks are malignant.

Back 191

True
pg 1587

Front 192

Angioedema of the upper airway in relation to medication reaction is treated with what meds?

Back 192

Benadryl 1-2mg/kg (max 50mg), Zyrtec 10mg, and methylprednisolone 125mg IV
pg 1591

Front 193

tox suck

Back 193

yes it does