Emergency Medicine Board Review

Tricia Falgiani, MD

EM Specific Subjects

• Anaphylaxis• Resuscitation• Environmental (bites, burns, drowning)• Acute Abdomen• Head Trauma • Orthopedics (fractures, dislocations)• Ophthalmology• Toxicology• Lacerations

Anaphylaxis

• IgE mediated• Clinical Findings

– Skin-puritis, urticaria, flushing, angioedema***Skin findings may be absent in up to 20%

– Respiratory-sneezing, cough, wheezing, dyspnea

– Cardiovascular-hypotension, dysrhythmias, myocardial ischemia

– GI-nausea, vomiting, abdominal cramps, diarrhea

Anaphylaxis

• Treatment– IntraMUSCULAR epinephrine– Corticosteroids– H1 antihistamine antagonist (Zyrtec, Benadryl)– H2 antihistamine antagonist (Zantac, Tagamet)– Nebulized albuterol– IV fluids and oxygen

• Prevention– Allergen Avoidance– Read food labels– Epi-pen– Written emergency action plan for accidental ingestion

Resuscitation

• Know PALS– ABCs– Bradycardia algorithm– Tachycardia algorithm– Pulseless arrest algorithm

• V-fib/V-tach• Asystole/ PEA

Bites• Rabies

– Bats, raccoons, skunks, foxes, coyotes: major carriers• Bat exposure consists of the following: actual bat bite,

exposure to bat fluids, bat found in room where child is sleeping, bat in close proximity to a child

– Dogs/cats can be a reservoir– Rodents (squirrels, rabbits, rats) DO NOT usually carry

rabies (low risk)– Observe domestic animal if not ill, euthanize if becomes

ill– Euthanize wild animal and test for rabies– Contact health dept– Rabies therapy

• As much of the dose as possible of rabies immune globulin (RIG) into the wound and the rest IM

• Rabies vaccine-5 doses on Day 0, 3, 7, 14, 28 (don’t give in the gluteus)

Dog/Cat Bites

• Sponge clean wounds• Do NOT irrigate puncture wounds• Give tetanus• Commonly infected with pasteurella• Abx for dog/cat/human/reptile bites

– Amoxicillin/Clavulanate– Bactrim + Clindamycin if pcn allergic

Snake Bites

• 95% in US are pit vipers (crotalidae-rattlesnakes, copperheads, cottonmouths)– Triangular head– Elliptical eyes– Pit between eye and nose

• Pit viper venom– Tissue necrosis (edema, ecchymosis, blistering)– Vascular leak (hypotension)– Coagulopathies– Neurotoxicity

• Children are susceptible because of low body mass

Snake Bites

• Signs/Symptoms– Develop within 2-6 hrs– Severe pain, N/V, weakness, muscle

fasciculations, coag abnormalities

• Treatment– ID snake– Immobilize extremity, wound pressure– Avoid tourniquet unless prolonged transport

time– No ice or excision or suction– IV lines, CBC, pain meds, tetanus– Antivenom is available (CroFab)

Spider Bites

• Black Widow-up to 3 inches in size with red/orange mark on back– Lives in basements and garages– Venom is a neurotoxin– Symptoms/Signs

• Pain at site• Muscle cramping• Chest tightness• Vomiting• Sweating• Abdominal pain• Agitation• Hypertension

Spider Bites

• Black Widow bite treatment– Mainly supportive– Opiates– Benzodiazepines– Antivenom is available for severe cases– IV calcium is ineffective– Resolves in 24-48 hrs

Spider Bites

• Brown recluse- ½ inch in size• Venom lyses cell walls• Symptoms/Signs

– Initially painless– Pain or itching around site– Hemorrhagic blister to large ulcer– Rare systemic symptoms

• Fever, chills, N/V, hemolysis, coagulopathy, DIC, shock

– Treatment• Admit if systemic symptoms• Hydration• Local wound care

Burns

• 2nd major cause of unintentional pediatric death

• Fires, scalds, flame, electrical, chemical• 18% of burns are due to abuse• Minor burns

– Infants with burns <10% BSA– Children with burns <15% BSA– No significant inhalation injury

• Major burns– Infants with burns >10% BSA– Children with burns >15% BSA– Significant inhalation injury

Burn First Aid

• Extinguish flames• ABCs• Remove clothing• Wash off chemicals• No grease, butter or ointments• Cover burn with clean dry sheet

– Cold, wet compresses to small burns– Cold, wet dressing on large burns will lead to

hypothermia

Burn Classification

• First Degree– Superficial redness, minor swelling, pain– Resolves in ~ 1week

• Second Degree– Blisters or Blebs, redness, pain– Takes 1-3 weeks to heal

• Third Degree– Dry, leathery, waxy, NO PAIN– Requires skin grafting if large

Burn Surface Area

• Rule of nines (>14 yo)– Head and Neck: 9%– Each upper limb: 9%– Thorax and abdomen front: 18%– Thorax and abdomen back: 18%– Perineum: 1%– Each lower limb: 9%

• Rule of palm (<10 yo)– Can use in small burns– Child’s palm (not including fingers) = 1% BSA– Or use an age appropriate burn chart

Minor Burn Care

• First degree requires no therapy• Second degree

– Clean with soap and water daily– Leave blisters intact, debride when ruptured– Antibiotic ointment (Silvadene or bacitracin)– Change dressing one time per day– Facial burn may be left open– Pain control– Update tetanus

Major Burn Care• ABCs

– Intubate early if going to require significant pain meds or if signs of airway edema

– Consider carbon monoxide poisoning• IVF for burns >15% of BSA• Urine output is the best indicator of hydration status

– Maintain UOP 1ml/kg/hr– Place foley catheter

• Parkland formula– 4cc X wt (kg) X %BSA burned– Give ½ the total volume in the first 8 hours and the other ½

volume in the subsequent 16 hours• Pain control• Circumferential burns are at risk for compartment

syndrome

Burns

• When to refer to a burn center– Burns > 15% of BSA– Larger burns of: hands, feet, face,

perineum– Concerns for abuse

Electrical Burns

• Minor electrical burns– Most are asymptomatic– Minor cleaning and antibiotic cream– Electrical cord bites with burns to the

oral commissure require follow up with a burn surgeon

Electrical Injuries

• High-tension, electrical wires or lightning– Serious: Admit all patients– Look for:

• Deep muscle injury• Cardiac arrhythmias• Seizures• Fractures (from severe muscle tetany)• Rhabdomyolysis and renal failure

– Electrical burns can show little surface area damage with deep-tissue burns present

Acute Abdomen

• Intussusception• Congenital abnormalities• Malrotation with volvulus• Appendicitis• GI perforation• Trauma• Testicular/ovarian torsion

Acute Abdomen

• Findings– Bilious vomiting– Blood in stools– Absent bowel sounds– Abdominal distention/rigidity– Rebound tenderness or involuntary

guarding– Localized tenderness– Exquisite pain with movement or walking

Head Trauma

• Common pediatric complaint• Most are not serious-require

observation only• Symptoms

– Vomiting– Lethargy– Headache– Irritability– Behavioral changes

Basilar Skull Fracture

• Raccoon eyes: bruising under eyes• Battle’s Sign: postauricular bruise• Raccoon eyes and battle’s sign take

hours to develop• Hemotympanum: blood behind

tympanic membrane• CSF otorrhea

Temporal Bone Fracture

• Bleeding from external auditory canal

• Hemotympanum• Hearing loss• Facial paralysis• CSF otorrhea

Head Injury

• Physical findings– Papilledema does not develop

immediately- takes weeks to months and is a LATE sign of intracranial hypertension

– Do a retinal exam in any patient with altered consciousness, coma or seizures to evaluate for retinal hemorrhage (Abuse!)

– Maintain a high index of suspicion for head injury in adolescents with drug or alcohol use

Head Injury

• Physical findings– Cushing’s triad (impending herniation)

• Bradycardia• Hypertension• Irregular respirations

– There does not have to be significant external signs (i.e. bruising, hematoma) to have a significant brain injury

Head Injury

• CT scan– Best for identifying intracranial injury– Can miss skull fractures

• Skull x-ray– Best study to diagnose skull fractures

Who to Image?

• Mild head injury with no LOC– Thorough history– Normal exam– Observe in office, ED or at home

• Mild head injury with brief LOC (<1min)– Thorough history– Normal exam– CT scan or observe in office/ED

Who to Image?

• Order head CT if– Penetrating trauma– LOC > 1 min– Altered level of consciousness– Focal neurologic abnormalities– Full fontanelle– Seizure– Amnesia for event– Signs of basilar or temporal fxs– Persistent vomiting– Progressive headache– Coagulopathy or bleeding disorder

Head Injury

• Treatment– Airway / Breathing

• Control C-spine• Intubate for GCS < 8• Normal ventilation (maintain PCO2 30-35)

– Circulation– Neurologic- mannitol or 3% saline for signs

of herniation– Prompt CT for detection of surgical lesion– Place OG tube- NG tubes are

contraindicated!

Concussion

• Trauma-induced alteration in mental status with or without loss of consciousness– Confusion– Loss of consciousness– Disturbance of vision– Loss of equilibrium– Amnesia– Headache or dizziness– Lethargy

• Perform neuro exam

Concussion

• Player must be asymptomatic for 1 week before returning to play

• Second-impact syndrome: head injury before full recovery from a previous injury can cause loss of autoregulation of cerebral blood flow with rapid development of increase intracranial pressure

Colorado Medical Society Guidelines

Grading and 1st Concussion guidelinesGrade Confusion Amnesia LOC Minimum

time to return to play

Time asymptomatic

I Yes No No 20 minutes When examined

II Yes Yes No 1 week 1 week

III Yes Yes Yes 1 month 1 week

Colorado Medical Society Guidelines for Return to Contact Sports after Repeated

ConcussionsGrade Minimum time to

return to playTime asymptomatic

I (2nd time) 2 weeks 1 week

II (2nd time) 1 month 1 week

III (2nd time)I, II (3rd time)

Season over 1 week

Orthopedics

• Must evaluate neurologic and vascular status– High risk fractures for neurovascular

injury• Supracondylar fractures• Any significantly displaced/deformed

fracture

Growth Plate Fractures

• Salter Harris Classification (SALTS)– I Separated through the physis– II Above (metaphysis)– III Lower (epiphysis)– IV Together (metaphysis + epiphysis)– V Smashed (compressed growth

plate)

Growth Plate Fractures

• I and V difficult to see on radiographs

• II is most common• III and IV require orthopedics• If you suspect a fracture with a

negative x-ray, treat as a fracture and x-ray again later

Greenstick Fracture

• Fractured cortex on the tension side and a plastic deformity on the compression side

• Not a complete fracture through the bone

• Deformity occurs and needs to be reduced

Torus Fracture

• Compression of the bone produces a torus (buckle) fracture

• An incomplete fracture (like greenstick fx)

• Most common in the distal metaphysis

• Heals well after 3 weeks of immobilization

Greenstick vs. Torus Fractures

• Greenstick– Incomplete fracture– Fracture of cortex on

the TENSION side– Plastic deformity on

compression side– Deformity occurs– Can be unstable

(deformity in splint/cast can worsen)

– Reduction usually required

• Torus– Incomplete fracture– Fracture of cortex on

the COMPRESSION side

– Cortex on tension side intact

– No deformity– Stable– No reduction if

angulation is insignificant

Spiral Fracture

• Fracture has a curvilinear course• Common in toddlers• Think abuse in children who are not

walking

Clavicle Fractures

• Most common fracture in childhood• Usually middle and lateral portion of

clavicle• Neurovascular injury uncommon• Treatment

– Place arm in sling– Heals in 3-6 weeks– Rarely requires surgery

Distal Humerus Fractures

• Supracondylar: Most common elbow fracture

• Fall on outstretched hand or elbow• Posterior fat pad sign increases

suspicion• High risk of complication!!

– Displaced fractures can have brachial artery, medial or radial nerve damage

Supracondylar Fractures Classification

• Type I - nondisplaced• Type II - displaced with intact

posterior cortex• Type III - displaced with no cortical

contact• Type III fractures increased risk of

neurovascular compromise & compartment syndrome.

• Orthopedic consult

Fracture Complications

• Neurovascular compromise• Compartment Syndrome

– Common with tibial fractures– Fracture, swelling vascular injury lead

to ischemia– Tissue blood flow compromised– Pulses may be normal– Pain out of proportion to fracture or

remote to the fracture site

Nursemaid’s Elbow

• Subluxation of the radial head• 6mos to 5 yrs• Mechanism: traction on a pronated wrist• Annular ligament slides over radial head• Affected arm with elbow slightly bend

held limply to child’s side• Exam: No tenderness to palpation at

elbow but pain with elbow movement• No x-ray necessary

Nursemaid’s Elbow

• Reduction:– Flexion of elbow with supination of the

forearm OR hyperpronation of the forearm

– Return of function within 15 min

Shoulder Injuries

• Acromioclavicular separation– Occurs in athletes (contact sports)– The clavicle separates from the scapula– Tenderness over the AC joint– Sling and pain meds for minor

separation– Referral to ortho for more severe

separations

Sprains

• Injury to the ligament around a joint• **Rare in prepubescent children-the

ligament is stronger than the growth plate and will cause a fracture rather than a sprain**

• Physical exam– Tenderness– Swelling– Bruising– Ligament laxity

Sprains

• Obtain x-ray to rule out fracture• Treatment: RICE (rest, ice,

compression and elevation)• Ice 20 min every 2 hours for 48

hours to prevent swelling• Severe sprain may require splint for

protection, comfort and stability

Eye Emergencies

• 1/3 of all blindness in children results from trauma

• Boys 11-15 yrs are most vulnerable• Injuries are caused by sports, sticks,

fireworks, paintballs and air-powered BB guns

Eye Emergencies

• Corneal abrasions– Pain, tearing, photophobia, decreased vision– Dx by fluorescein dye and slit lamp/woods

lamp exam– Abrasions are transparent, ulcers are opaque

but both light up under fluorescein– Tx: Topical antibiotic ointment and recheck

the next day (do not send home on topical anesthetics, i.e. tetracaine)

– Remember to check for corneal abrasion in an irritable infant!

Eye Emergencies

• Penetrating globe injury– Protect eye with styrofoam cup or rigid

eye shield– Minimal manipulation– May be missed because can seal over – Do not put pressure on the globe– May cause a distorted pupil or collapse

of the anterior chamber– Think about this if there is broken glass

involved!!

Eye Emergencies

• Hyphema– Blood in the anterior chamber– Caused by blunt or perforating injury– Bright or dark red fluid between the

cornea and iris– Causes eye pain and somnolence– Tx: bed rest, elevated head of bed 30-45

degrees, may use topical steroids and oral amniocaproic acid

Eye Emergencies

• Chemical burns– Alkali burns are the worst-they can

penetrate very deep into the eye– Acids cause less severe, localized tissue

damage– Both can cause corneal opacification– Immediately treat with copious amounts

or saline irrigation (may need 5-6 LITERS)

– Use pH paper- want neutral pH

Eye Emergencies

• Lacerations of the eyelid– Need optho to repair in the OR– Lac to upper lid may involve the levator

or tarsal plate– Lacs near medial canthus may involve

the nasolacrimal duct (requires microsurgical repair)

– Examine the globe for penetrating injury

Eye Emergencies

• Blowout fracture– Fracture of the walls or the floor of the orbit– Occur with blunt trauma (balls, fist, etc)– Dx by CT or plain x-ray (Waters view)– Signs

• Limitation of upward gaze (causes diplopia)-caused by entrapment of the inferior rectus muscle

• Nosebleed• Orbital emphysema• Hypesthesia of the ipsilateral cheek and upper

lip

Toxicology

• Lots of Tox on the Boards!• 2 million events/yr• 60% are less than 6 yrs old• Peak age: 18mo- 3yrs• 92% occur at home• 92% involve 1 substance• 75% are managed at home

Who gets poisoned?

• 85% unintentional– Toddlers– Boys>girls– Looks like candy– Exploratory– 60% are non-pharmaceutical ingestions

• 15% intentional– Adolescents and adults– Girls > boys– Usually ingest pharmaceuticals

Poison Control Centers

• Good source for information-such as signs/symptoms of toxicity, management, etc.

• Can provide recommendations for home care

• Can calculate dosage toxicities• Identification of ingested substances

Poison Management

• Prevention!!– Discuss storage of poisonous substances

at the 6 mo visit!!

• ABCDs and stabilize• Identify the toxin• Prevent further absorption of toxin• Enhance elimination of toxin• Antagonists and antidotes• Decontaminate-remove clothing

Poison Management

• What?– Home search, bring the container

• When?– Useful in interpreting drug levels

• How?– Route and site of exposure– Intentional vs. unintentional

• How much?– “Worst case scenario”– Average swallow of young child: 5-10 cc, of

older child or adolescent: 10-15 cc

Poison Management

• Exam– ABCs– HR, RR, Blood pressure– Neuro status– Pupillary exam (key to some

toxidromes)– Breath odor– Skin: temp, color, diaphoresis

Poison Management

• Labs– CBC, LFTs– Accucheck– Measured (not calculated) serum osmolality– Anion gap– ECG– Arterial ABG (determine acid-base status)– Drug levels (aspirin, acetaminophen,

alcohols)– Abdominal x-ray

Poison Management

• Prevention of absorption– Dermal: remove clothing, wash skin (15

min)– Ocular: irrigate eyes with normal saline– Respiratory: remove pt to fresh air– Prevent GI absorption

• Activated charcoal• Gastric lavage• Cathartics• Whole bowel irrigation

GI Decontamination

• Most liquids absorbed in 30 min• Most solids absorbed in 1-2 hrs• Contraindication to GI

decontamination– Coma or altered mental status (no airway

protection)– Hematemesis– Seizures– Hydrocarbon ingestion– Acids, alkalis and sharp objects

GI Decontamination

• Ipecac– NOT recommended by the AAP!!– No home use

GI Decontamination

• Activated charcoal– Most commonly used method– Adsorbs the ingested substance– Dose = 1gram/kg– Most benefit if given within 1 hr of

ingestion

GI Decontamination

• Activated charcoal– Complications

• Pulmonary aspiration• Emesis• Constipation or intestinal obstruction

– Contraindications• Hydrocarbons or corrosives• Ileus• Compromised airway/ altered mental status

GI Decontamination

• Activated charcoal ineffective= CHEMICaL CamP– C cyanide C camphor– H hydrocarbon P phosphorus– E ethanol– M metals– I iron– C caustics– L lithium

GI Decontamination

• Gastric lavage– Not routine– Consider if life-threatening ingestion

within 30-60 min– Absence of pill fragments does not rule

out toxic ingestion– Requires large bore tube, lavage until

clear

GI Decontamination

• Gastric lavage– Complications

• Aspiration• Laryngospasm• Mechanical injury to throat/esophagus/stomach• Fluid and electrolyte imbalance

– Contraindications• Hydrocarbon, acid, alkali ingestion• Compromised airway/ altered mental status• Patients with GI pathology (ulcers, recent

surgery)

GI Decontamination

• Cathartics– Limited use, only 1 dose recommended

if used– Sorbitol is most commonly used agent– Never used alone-mixed with charcoal– Side effects: Nausea, abd cramps,

vomiting, transient hypotension– Can cause dehydration, hypernatremia

if multiple doses given

GI Decontamination

• Whole bowel irrigation– Cleanses the whole bowel– Uses polyethylene glycol electrolyte

solution– Useful for iron, concretions (aspirin),

drug-filled packets, sustained release drugs

– Potential to reduce drug absorption by decontamination or the whole GI tract

GI Decontamination

• Whole bowel irrigation– Contraindications

• Bowel perforation• Bowel obstruction• Ileus• Compromised airway/ altered mental status• Hemodynamic instability• Intractable vomiting

Tox Mnemonics

• Miosis (small pupils) = COPS– C cholinergics, clonidine– O opiates, organophosphates– P phenothiazine, pilocarpine,

physostigmine– S sedatives (barbituates)

Tox Mnemonics

• Mydriasis (dilated pupils) = AAAS– A antihistamine– A antidepressant– A anticholinergic, atropine– S sympathomemetics (amphetamine,

cocaine, PCP)

Tox Mnemonics

• Diaphoretic skin = SOAP– S sympathomimetics– O organophosphates– A asa (salicylates)– P phencyclidine (PCP

• Red skin= carbon monoxide, boric acid• Blue skin=cyanosis,

methemoglobinemia

Tox Mnemonics

• S salivation• L lacrimation• U urination• D diarrhea• G GI distress• E emesis

• D diarrhea, defecation

• U urination• M miosis, muscle • B bradycardia• B bronchospasm,

bronchorrhea• E emesis• L lacrimation• S sweating,

salivation

Organophosphates= SLUDGE or DUMBBELS

Tox Mnemonics

• Compounds visible on abd x-ray=CHIPES– C chloral hydrate, calcium, cocaine

condoms– H heavy metals, halogenated hydrocarbons– I iron, iodine– P phenothiazine, potassium, pepto-bismol– E enteric coated tabs– S salicylates, sustained-release tabs

Tox Mnemonics

• Increased anion gap= MUDPILES– M methanol– U uremia– D DKA– P phenols, paraldehyde– I iron, isoniazid, inhalants, ibuprofen,

inborn errors– L lactate (CO, cyanide)– E ethanol, ethylene glycol– S salicylates, solvents (benzene, toluene)

Tox Mnemonics

• Increased osmolar gap= MAD GAS– M mannitol– A alcohols and glycols – D diatrizoate (iodine contrast agent)– G glycerol– A acetone– S sorbitol

Tox Mnemonics

• Hypoglycemia = HOBIES– H hypoglycemia– O oral hypoglycemics– B beta blockers– I insulin– E ethanol– S salicylates

Pharmaceutical Ingestions

• Content specifications for specific substances– Acetaminophen Salicylates– Anticholinergics Theophylline– Clonidine Tricyclic

Antidepressants– Ibuprofen– Iron– Opiates– Phenothiazines

Acetaminophen

• Rapidly absorbed• Metabolized in liver using

glutathione• In toxicity, glutathione stores

overwhelmed and toxic metabolite accumulates

• Commonly combined with other drugs (lortab, roxicet, etc)

Acetaminophen

• Acute toxic dose– Minimum toxic dose 150mg/kg– Healthy children 1-6 yo: 200mg/kg– Adolescents and adults: 7.5 grams

• Chronic toxic dose– Repeated large doses may lead to

toxicity– More subacute course

Acetaminophen

• Overdose symptoms– 0-24hrs: GI irritation

• Nausea, vomiting, normal LFTs– 24-48hrs: Latent period

• Asymptomatic• RUQ pain develops• LFTs increase

– 48-96hrs: Hepatic failure• Peak symptoms• AST> 2000, prolonged PT, elevated bilirubin• Coagulopathy

– 4-14days: Recovery or death• Death from hepatic failure• Symptoms resolve in survivors

Acetaminophen

• Management– Prevent absorption: activated charcoal– Acetaminophen levels

• Peak concentration at 4 hrs post ingestion• Remember patient is asymptomatic when

damage is occurring! • Rumack-Matthew nomogram

– Used for single acute poisoning– Can not be used if time of ingestion is unknown

or if repeated supratherapeutic ingestion

Acetaminophen

• Rumack-Matthew nomogram

Acetaminophen

• Overdose treatment– N-acetylcysteine (NAC)- IV form– Acetylcysteine (Mucomyst)- oral form– Give for toxic levels– Must give full course if started– IV is as effective as PO– Regenerates glutathione stores to be

able to metabolize the acetaminophen to a nontoxic metabolite

Anticholinergics

• Blocks acetylcholine (ACH) at muscarinic receptors

• Examples– Atropine Belladona– Antihistamines Muscle relaxants– Phenothiazines Mushrooms– TCAs Jimson weed

Anticholinergics

• Hot as a hare: hyperthermia, tachycardia• Blind as a bat: mydriasis (blurred vision)• Red as a beet: flushed skin• Dry as a bone: decreased sweat, urine,

dry mucous membranes• Mad as a hatter: delirium, seizures,

agitation• Bloated as a bladder: urinary retention

Anticholinergics

• Treatment– Activated charcoal if good mental status– Supportive care– Physostigmine

• Reversibly inhibits cholinesterases and allows ACH to accumulate

• Use is controversial

Clonidine

• Antihypertensive with alpha-2-adrenergic receptor stimulation

• Children are very sensitive (0.1mg is toxic)

• Rapid onset (1hr)• Gastric decontamination not helpful• Get ECG and blood gas• Supportive care• Resolves within 24 hrs of ingestion

Clonidine

• Signs/ Symptoms– Lethargy– Miosis (remember COPS)– Bradycardia– Apnea– Coma– Hypotension– ***May cause transient

HYPERtension****

Ibuprofen

• Serious side effects are rare• <100 mg/kg does not cause toxicity• >400 mg/kg can cause serious

toxicity• Symptoms within 4 hrs and resolve

within 24 hrs– Nausea, vomiting, epigastric pain,

drowsiness, lethargy, ataxia

Ibuprofen

• Causes anion gap metabolic acidosis• Renal failure• Coma or seizures (rare)

• Treatment– Activated charcoal– Supportive care– Monitor renal function and acid/base

status

Iron

• Serious toxicity• Prenatal vitamins, iron supplements• Pathophysiology

– Corrosive to gastric/intestinal mucosa (strictures)

– Mitochondrial and cell dysfunction– Capillary leak leads to hypotension

• Toxic dose– 60mg/kg of elemental iron

Phases of Iron Toxicity• Phase 1: GI stage (30min-6hrs)

– N/V, diarrhea, abd pain, hematemesis– Direct damage to GI/intestinal mucosa

• Phase 2: Stability (6-12hrs)• Phase 3: Systemic toxicity (within 48hrs)

– Cardiovascular collapse– Severe metabolic acidosis (high anion gap)

• Phase 4: Hepatic toxicity (2-3 days)– Hepatic failure

• Phase 5: GI scarring (2-6 weeks)

• IRON= Indigestion, Recovery, Oh my Gosh (stage 3,4), Narrowing

Iron

• Diagnosis– X-ray may confirm ingestion

• Liquid preps and chewables not visible

– Obtain serum iron levels• 4 hrs after ingestion• <300mcg/dL: minimal toxicity• >500mcg/dL: severe toxicity

Iron

• Treatment– Supportive and symptomatic care– Chelation with IV deferoxamine

• Binds free iron in serum• Treat if iron level 350-500 +symptoms• Treat all iron level >500• Treat if ingested dose >60mg/kg• Patients will develop “vin rose” urine• Does not treat corrosive effects of iron in

the GI tract

Iron

• Therapy adjuvants– Whole bowel irrigation– Endoscopic gastric pill removal– Do NOT use ipecac, gastric lavage – Activated charcoal does NOT bind iron

Opiates

• Most cases present from drug abuse• Acts on receptors in the brain• Ex: Morphine, heroin, methadone,

codeine, meperidine

Opiates

• Symptoms– Drowsiness– Coma– Change in mood– Analgesia– N/V– Respiratory

depression– Abdominal pain

• Physical Findings– Miosis– Respiratory

depression– Coma– Decreased GI

motility– Hypotension– Bradycardia– Hypothermia– Hyporeflexia

Respiratory and CNS depression with pinpoint pupils = Opiate overdose

Opiates

• Treatment– ABCs– Intubation– Naloxone (Narcan) is the antidote

• use if respiratory depression• Can be give Sub-cutaneously or IV• Dose: 0.1-0.4mg/kg• Short acting-may need to redose if opioid is long-

acting• Can precipitate opioid withdraw in chronic opiate

users

Phenothiazines

• Promethazine, prochlorperazine, chlorpromazine (antipsychotics)

• Symptoms– Anticholinergic symptoms– CNS depression– Hypotension– **Transient HYPERtension**– Cogwheel rigidity– Dystonic reaction: neck spasms, tongue

protrusion, oculogyric crisis

Phenothiazines

• Treatment– ABCs– Vasoactive drugs for hypotension– Diphenhydramine for dystonic reactions– Can use charcoal if not contraindicated

***Remember Phenothiazines and clonidine can cause transient HYPERtension***

Salicylates

• Aspirin, oil of wintergreen, antidiarrheal products

• Pathophys: uncouples oxidative phosphorylation

• Acute toxic dose: 150mg/kg

Salicylates• Signs and Symptoms

– N/V– Tinnitus– Hyperventilation, respiratory alkalosis– Increased respiratory depth– Dehydration– Hypokalemia– Metabolic acidosis– Renal failure

• Serious toxicity: hyperthermia, agitation, confusion, coma

• Death occurs from pulmonary or cerebral edema, electrolyte imbalance, cardiovascular collapse

Salicylates

• Diagnosis– Levels >30 mg/dL potentially toxic– Levels > 40mg/dL symptomatic– Levels >100mg/dL serious toxicity– Serially monitor levels– Labs: ABG, electrolytes, coags

Salicylates

• Treatment– Activated charcoal-drug may form

bezoar/concretions-may need multiple doses of charcoal

– Aggressive fluid rehydration– Replace bicarbonate and potassium– Raise urine pH-enhances excretion– Hemodialysis

Theophylline

• Narrow therapeutic window– Therapeutic level 10-20mcg/dL– >20 mcg/dL toxic

• Signs/Symptoms– N/V Hypercalcemia– Mental status changes Hypokalemia– Seizures Metabolic

acidosis– Hypotension– Tachyarrhythmias

Theophylline

• Treatment– Repeated doses of activated charcoal– ABCs– Cardiac monitoring– Treat arrhythmias with beta blockers– Treat hypotension with fluids and pressors– Benzos for seizures– Monitor theophylline levels– BMP– Hemodialysis

Tricyclic Antidepressants

• Usually prescribed to adolescents• Danger of accidental ingestion by

siblings• Onset of symptoms within 2 hrs• Major complications occur within 6 hrs• Labs:

– BMP (hypokalemia)– ABG (acidosis)– ECG– Urine tox screen: Look for co-ingestions!!

Tricyclic Antidepressants• Signs/Symptoms

– Acidosis– Anticholinergic symptoms (dry, flushed skin, mydriasis,

decreased bowel sounds, hyperthermia)– CNS effects

• Lethargy• Agitation• Seizures• Coma

– Cardiovascular effects• Tachycardia• Hyper or Hypo-tension• Widened QRS• Prolonged QT**Cardiac dysrhythmias occur LATE**

The ECG in TCA Overdose

• Sinus tachycardia• Right Axis Deviation of the Terminal 40 msec

– R wave in AvR– S wave in I

• QT prolongation• Prolonged QRS: blockage of fast Na+

channels slows depolarization of action potential and delays ventricular depolarization– >100 msec: risk for seizures– >160 msec: risk for arrhythmias

Tricyclic Antidepressants

• Treatment– ABCs– Charcoal– Continuous ECG monitoring– IV sodium bicarb drip-want pH 7.45-7.55 to

prevent dysrhythmias– Do not use physostigmine– Treat seizures with benzos or phenobarb, do

not use phenytoin– Monitor potassium closely

Environmental Ingestions

• Content specifications for specific substances– Carbon monoxide Plants– Acids/Alkali

Esophageal FB– Hydrocarbons– Ethanol– Methanol– Ethylene glycol– Organophosphates

Carbon Monoxide

• Pathophysiology– Reversibly binds to hemoglobin and

displaces oxygen– Impairs oxygen release (shifts curve to

the left)– Impedes oxygen utilization– Colorless– Odorless– May cause cherry red skin

Carbon Monoxide

• Symptoms– Headache– Dizziness– Nausea, vomiting– Visual changes– Weakness– Syncope– Ataxia– Seizures, coma death

Carbon Monoxide

• Labs– Obtain CO concentration (carboxyhemoglobin)– >15-20% CO symptomatic– Pulse ox may be NORMAL

• Treatment– Oxygen-give by high-flow non-rebreather face

mask– Cardiac monitoring– Correct anemia– Hyperbaric chamber therapy is controversial– Consider cyanide poison if from a house fire

Caustic Ingestions

• Acidic agents– Toilet bowel cleaners, rust remover, metal

cleaners– Bitter– Superficial coagulation necrosis– Thick eschar formation– Severe gastritis

• Alkali agents– Oven and drain cleaners, hair relaxer,

automatic dishwasher detergent– Tasteless– Severe, deep liquefaction necrosis– Household bleach (5%) is only an irritant

Caustic Ingestions

• Signs and symptoms– Drooling– Refusal to drink– Vomiting– Oral burns– Dysphagia– Stridor or resp distress– Chest or abdominal pain

Caustic Ingestions

• Work-up– No symptoms usually means little or no injury– Patients with esophageal burns:

• 60-80% have burns to the mouth• 20-45% have NO burns to the mouth**Absence or oral lesions does not preclude

severe esophageal or stomach injury**

– Upper endoscopy (12 hrs after ingestion) for all patients with oral burns or symptoms

– CXR

Caustic Ingestions

• Treatment– Remove contaminated clothing– Observe for complications– NO gastric lavage or activated

charcoal– Endoscopy within 24-48 hrs-evaluate for

burns, perforation, severe gastritis**May have late stricture formation**

Caustic Ingestions

• Complications– Necrosis– Esophagitis– Perforation– Stricture formation

Caustic Ingestions

• Hydrochloric or sulfuric acids can cause:– Severe gastritis– Perforation– Peritonitis– Late strictures– All of these can happen without

evidence of oral or esophageal burns!!

Hydrocarbon Ingestion

• Mineral spirits, kerosene, gasoline, lamp oil

• Low viscosity leads to pulmonary aspiration

• Carbon tetrachloride causes liver toxicity

• Inhaled propellants, refrigerants, toluene sensitize to cardiac arrhythmias

Hydrocarbon Ingestion

• Clinical findings– Coughing, choking, gagging– Tachypnea, wheezing, resp distress– Mild CNS depression– Fever

• Labs– Leukocytosis– CXR (may be normal for up to 24 hrs

after exposure)

Hydrocarbon Ingestion

• Treatment– Dermal decontamination– Observe for 6 hrs and discharge if:

• Patient presented without symptoms• Remains asymptomatic• No findings on CXR• Normal O2 sats

– If symptomatic at any time or if positive x-ray admit for:

• Supportive care• Airway control• ARDS treatment

Hydrocarbon Ingestion

• DO NOT:– Use ipecac– Gastric lavage– Activated charcoal– Steroids– Prophylactic antibiotics – Epinephrine

Ethanol

• Found in multiple products in the home: mouthwash, perfume

• Signs/ Symptoms– CNS depression– N/V– Slurred speech– Ataxia– Stupor– Seizures, coma– Hypothermia– Hypoglycemia (inhibits hepatic

gluconeogenesis)

Ethanol

• Labs– Ethanol level– Elevated osmolar gap– Elevated anion gap (anion gap acidosis)

• Treatment– ABCs– IV fluids– Treat hypoglycemia and hypokalemia– No activated charcoal– Hemodialysis rarely used

• Ethanol intoxication may mask toxicities from co-ingestions.

Methanol

• Windshield washer fluid, de-icing agents, solvents, canned heat (sterno), liquid fuels

• Peak methanol levels in 1 hr• 80-90% hepatic metabolism• Methanol itself is harmless

– It’s metabolite, FORMIC ACID, is extremely toxic

Methanol

• Signs/ Symptoms– Initially: N/V, abdominal discomfort– 24hrs later:

•Visual disturbance: blurry vision, photophobia, snowstorm

• Optic nerve damage leads to blindness• CNS depression, coma, seizures• Severe metabolic acidosis

Methanol

• Labs– Methanol level– Elevated osmolar gap– Elevated anion gap (anion gap

acidosis)

Methanol

• Treatment– Activated charcoal NOT effective– Sodium bicarb for acidosis– Hemodialysis (also corrects acidosis)– Antidotes:

• IV ethanol• Fomepizole (inhibits alcohol dehydrogenase and

prevents the metabolism of methanol to toxic metabolite)

• Folic acid/ leucovorin (helps convert formic acid into CO2 and H2O)

Ethylene Glycol

• Radiator fluid, antifreeze, coolants, inks, adhesives, glass cleaners

• Peak level 1-4 hrs• 80% hepatic metabolism• Again it’s metabolites are toxic:

– Glycolic acid– Oxalic acid (forms calcium oxalate

crystals)

Ethylene Glycol

• Signs/ Symptoms– Stage 1 (1-12 hrs): Intoxication

• N/V, drowsiness, slurred speech, lethargy– Stage 2 (12-36 hrs)

• Tachypnea• Cyanosis• ARDS or pulmonary edema• Coma, seizures• Metabolic acidosis

– Stage 3 (2-3 days)• Cardiac failure, renal failure• Cerebral edema• DEATH

Ethylene Glycol

• Labs– Ethylene glycol level– Elevated osmolar gap– Elevated anion gap (anion gap acidosis)– Urine fluoresces under woods lamp– BMP-monitor BUN/ Cr., calcium (oxalate binds

ca)– Falsely elevated lactate (analyzers interpret

glycolic acid as lactic acid)– UA-look for calcium oxalate crystals

Ethylene Glycol

• Treatment– Activated charcoal NOT effective– Sodium bicarb for acidosis– Calcium for symptomatic hypocalcemia– Hemodialysis (also corrects acidosis)– Antidotes:

• IV ethanol•Fomepizole (inhibits alcohol

dehydrogenase and prevents the metabolism of methanol to toxic metabolite)

Organophosphates

• Pesticides: diazinon, malathion• Binds to cholinesterase leading to

excess acetylcholine (can’t break down ACH)

• Bond becomes permanent in 2-3 days

• Takes weeks to months to regenerate enzyme

Organophosphates

• Symptoms: SLUDGE & DUMBELS• Nicotinic symptoms

– Muscle twitching, weakness, tremors– Respiratory weakness– Confusion– Coma– Slurred speech– Seizures– Altered mental status

Organophosphates

• Treatment– Provider must wear protective clothing– ABCs– Decontaminate, wash skin with soap/water– Benzos for CNS symptoms– Antidotes:

• Atropine for increased secretions, bradycardia• Pralidoxime (2-PAM)

– Reactivates acetylcholinesterase activity– only effective before bond becomes permanent– Use with atropine

Plants

• Contact poison control as your resource

• GI upset most common symptom• Dieffenbachia and philodendron are

house plants that cause oral pain• Poinsettia, mistletoe and holly cause

GI symptoms

Plants

• Foxglove, oleander and lily of the valley have digitalis-like toxicity

• Jimson weed, deadly nightshade cause anticholinergic poisoning

• Lethal mushrooms have delayed symptoms (liver toxicity)

Esophageal Foreign Bodies

• Children 6mo -3 yrs • Coins the most common• Get stuck at:

– Upper esophageal sphincter (cricopharyngeal muscle)

– Aortic arch– Lower esophageal sphincter

(gastroesphageal junction)

Esophageal Foreign Bodies

• Signs/ Symptoms– 30% asymptomatic (take all seriously)– Drooling– Dysphagia– Choking, gagging, vomiting– Cough, stridor, wheezing, dyspnea– Pain in neck, throat, chest

Esophageal Foreign Bodies

• Diagnosis– Radiograph

• Coin flat on AP (get lateral to look for multiple coins)

• Coin on edge on AP if in trachea

– Radiolucent objects• Endoscopy• Contrast esophagram

– Metal detector

Esophageal Foreign Bodies

• Treatment– Observe for 24 hours if:

• No symptoms• <24 hrs old• Blunt object

– Endoscopic removal• Gold standard• Urgent for respiratory symptoms

– Foley catheter extraction under fluoroscopy– Push object into stomach using a

bougienage

Esophageal Foreign Bodies

• Disc/ Button Batteries– Liquefaction necrosis and perforation can

occur if disc battery is lodged in esophagus– Batteries in esophagus should be removed

IMMEDIATELY (mucosal injury w/in 1 hr, full thickness injury w/in 4 hrs)

– If the disc battery is in the stomach:• Most pass without consequence- monitor stools• Do not need to be retrieved unless remains in the

stomach >48 hrs or is a large diameter battery (>20mm)

Lacerations/Wounds

• Laceration Tips– Irrigation is the best method of

cleansing– Update tetanus– No topical skin adhesives in scalp or

bites– No LET gel on fingers, nose, toes, penis– Eyelid lacs require an ophthalmologist

for repair

Lacerations/Wounds

• Wound management– Hemostasis– History of wound mechanism– Tetanus immunization history– Thorough wound cleaning– Remove debris– Debride devitalized tissue– Closure of wound

Lacerations/Wounds

• Lip lacs– Lac through vermillion border requires

exact approximation of the wound margins

– Must take into consideration swelling of the soft tissue of the lips

Lacerations/Wounds

• Wound cleaning– Irrigation with mild pressure– Remove dirt or foreign bodies– Iodine use is controversial– Debride necrotic tissue– Do NOT shave hair or eyebrows

Lacerations/Wounds

• Laceration complications– Tendon laceration– Arterial damage– Infection– Limited movement due to scar

formation– Scarring– Keloid formation

Lacerations/Wounds

• Puncture wounds– Primary closure is not necessary– Obtain x-rays to look for foreign body– Prophylactic antibiotics usually not

indicated– Complications

• Secondary infection (6-10%)• Retained foreign body• Osteochondritis (esp with puncture wounds

of hands or feet)

Puncture Wounds

• Common causes of infection– Staphylococcus– Streptococcus– Pseudomonas (esp if puncture wound

through a sneaker)

Lacerations/Wounds

• Tetanus– Children with 3 or more immunizations:

• Clean, minor wound: no tetanus if last dose w/in 10yrs

• All other wounds: give tetanus if more than 5 yrs since last dose

– If tetanus status unknown or less than 3 doses• Clean, minor wound: give TD• All other wounds: give TD and tetanus immune

globulin

Pathologist on TrialDuring a murder trail, a pathologist was cross-examined by a defense attorney. Attorney: Did you take a pulse before you gave the death certificate?Pathologist: No.Attorney: Did you listen to the heart?Pathologist: No.Attorney: Did you check for breathing?Pathologist: No.Attorney: This means that you were not sure that the patient was dead when you signed the death certificate?Pathologist: Let me put it this way. The man’s brain was in a jar on my desk. But I guess it’s possible he could be out there practicing law somewhere.