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GreenC2 ER, Toxicolo
Board Review
| Question | Answer |
|---|---|
| Who gets poisoned, how many substance involved and the most common managment? | 50% <6yo (peak 1-2yo); 90% involve 1 substance, 72% managed at home Majority occur at home |
| Most common pediatric poisons | cosmetics, analgesics, cleaning substance, foreign bodies, topicals, vitamins, antihistamins, cold/cough preps, pesticides, plants |
| Most common adolescent ingestions | 25% intentional, pharmaceuticals more common: acentaminophen, barbituates, stimulants, antidepressants, and alcohol |
| When do you discuss storage of poisons? | 6 month well child check |
| What has decreased the mortality of unintentional ingestions by 45%? | childproof caps |
| What is the average swallow of a young child? | 5-10cc, most kids take a swallowful |
| What is the average swallow of an older child or adolescent? | 10-15cc |
| What aspects of a physical/ are important in analysing a poisoning case? | HR, RR, BP, Neuro status, pupillary findings, breath odor, skin (temp, color, diaphoresis) |
| Poisoning: FAST heart rate causes | Freebase cocaine, Anticholingergics, Sympathomimetics, Theophyline, |
| Poisoning: slow heart rate causes PACED | Propanolol, Anticholinesterase drugs, Clonidine, Ethanol, Digoxin, |
| Examples of anticholinesterase drugs | Carbamates (physostigmine, neostigmine), edrophonium-short duration, organophosphates, THC, Galantamine |
| Poisons that cause Miosis- COPS | Cholingerics, Clonidine; Opiates, Organophosphates; Phenothiazine, Pilocarpine; Sedative (barbituates); |
| Poisons that cause Mydriases- AAAS | Antihisatamine, Antidepressant, Anticholingerics, Sympathomimetics (amphetamine, cocaine, PCP) |
| Poisons that cause diaphoretic skin- SOAP | Sympathomimetics, Organophosphates, ASA (salicylates- aspirin or peptobismal), PCP (phencyclidine) |
| Poisons that cause red skin- ABC | Anticholingerics Boric acid, Carbon monoxide |
| Poisons that cause blue skin | Methemoglobinemia agents |
| Toxidrome: Anticholinergic (antihistamine, phenothiazines) | BLIND as a BAT (mydriasis), HOT as a HARE (hyperhermia), RED as a BEET (flushing), DRY as a BONE (dec UOP, dec sweating), MAD as a HATTER (delirium, hallucinations) |
| Radiolucent pill fragments (COINS) | Chloral hydrate, calcium; Opium packets; I \ron, other heavy metals; Neuroleptic agents; Sustained-relese or enteric-coated agents |
| Cardiotoxic drugs and EKG finding | tricylic ingestions: prolonged QRS |
| Drug screens and other testing- confirmatory testing after H&P | Drug levels: acetaminophen, salicylate, ethanol; Also chech CBC, renal panel, LFTs, osmolality |
| What ingestions cause hypoglycemia? (HoBBIES) | Hypoglyceimic oral agents, Beta blockers, Insulin, Ethanol, Salicylates |
| Osmolar gap equation | Osmolar gap= (measured-calculated osmoles); (2 x Na)+(BUN/2.8)+(glucose/18) |
| Osmolar gap >10 | alcohol ingestions |
| Anion gap equation | Anion Gap= Na-(Cl + HCO3) |
| Anion gap >12 (MUDPILES) | Methanol, uremia, DKA, phenols, iron, INH, lactate, ethanol, ethylene glycol, salicylates |
| Approach to the Poisoned patient | ABCs, DONT (Dextrose, Oxygen, Naloxone, Thiamine), and Decontaminate (remove clothing, wash skin with soap and water, irrigate eyes with 1000cc normal saline sln, get into fresh air) |
| Absorption time for ingested liquids | 30 minutes |
| Absortpion time for ingested solids | 1-2hrs |
| Ipecac- GI decontamination | Rare hosp use, NO home use, ineffective, may help in extremely large, recent, toxic, long-acting ingestions without other therapy |
| Activated charcoal- GI decontamination action, and when best to use | adsorbs the ingested substance which dec bioavailability, best within 1hr of ingestion, may need to repeat doses |
| Complications of Activated Charcoal | pulmonary aspiration, emesis, constipation |
| Contraindications of Activated Charcoal | hydrocarbons, corrosives, illeus, compromised airway |
| Charcoal is ineffective with: (CHEMICaL CamP)- mostly things found in the garage | Cyanide, Hydrocarbon, Ethanol, Metals, Iron, Caustics, Lithium; Camphor, Phosphorus |
| Gastric Lavage- use | only within 30-60min of a life-threatening ingestion, older children and adults only |
| Gastric Lavage- contraindications | hydrocarbons, acids, alkalis, sharp ingestions, and altered mental status |
| Gastric Lavage- complication | pulmonary aspiration |
| Cathartics- GI decontamination actino and use | decreases GI transit time? never used alone- often used in combo with activated charcoal, use only one dose |
| Acetaminophen peak plasma level | 1hour |
| Acetaminophen toxicity mechanism | metabolized in liver using glutathione, glutathione stores are overwhelmed and toxic metabolite accumulate |
| Acetaminophen acute toxic dose | 150mg/kg minimum dose, 7.5gms teens/adults |
| Acetaminophen chronic toxic dose | 150mg/kg/day > 2days OR 4gm/day >2day |
| Acetaminophen overdose symptoms- 1st 48hrs | 0-24hrs: GI irritation (N/V, nl LFTs); 24-48hrs: Latent period (asymptomatic, RUQ pain, LFTs may increase) |
| Acetaminophen overdose symptoms- after 48hrs | 48-96hrs: Hepatic Failure (peak s/s) AST>20,000 with prolonged PT, death is from hepatic failure or coagulopathy. 4day-14days: Recovery or Death |
| Acetaminophen overdose management | prevent absorption- activated charcoal; check acetaminophen levels |
| Rumack-Matthew nomogram | used in managing acetaminophen overdose, and used only for single dose ingestion. |
| When is the peak concentration of acetaminophen on the Rumack-Matthew nomogram? | 4hrs post ingestion |
| What percentage of patients will develop hepatic toxicity if they are above the "probable hepatic toxicity line" on the Rumack-Matthew nomograms? | 60% |
| Acetaminophen antidote? | N-acetylcysteine (NAC) given IV or acetylcysteine (Mucomyst) |
| What is the timeframe for acetaminphen antidote admninistration? | give within 8hrs of ingestion |
| What labs do you follow in an acetaminphen overdose managment? | AST, ALT, PT, PTT |
| How often do you check drug levels for acetaminophen overdose managment? | Once, the initial toxicity level is all that is needed. Consider co-ingestions though! |
| Examples of anticholinergics: | diphenhydramine (benadryl), atropine, OTC antispasmodics, mushrooms, jimson weed, deadly nighthsade, TCA |
| Symptoms of anticholinergic toxicity | HOT as HARE (hyperthermia), BLIND as a BAT (mydriasis), DRY as a BONE (dec sweat/UOP), RED as a BEET (flushing), MAD as a HATTER (aggitation, seizures) |
| Treatment of anticholinergic toxicity | Activated charcoal, supportive care, Physostigmine use is controversial |
| Clonidine ingestion (antihypertensive)- importance | children are very sensitive- small amount is very toxic (0.1mg) |
| Clonidine- how does it act | centrally acting antihypertensive, in 24hrs |
| Clonidine toxicity signs (similar to opioids) | apnea, bradycardia, hypotension, lethargy, miosis (COPS), transient hypertension |
| Treatment of Clonidine toxicity | supportive care only- intubation, atropine, dopamine, naloxone? |
| What do you check with Clonidine toxicity | ECG and blood gases |
| Age limits for use of cold meds in kids | AAP- no use in <6yo, FDA- no use in <2yo, drug manufacturers- no use in <4yo |
| Reasons for age limits in cold meds usage | lack of evidense for efficacy, toxicity |
| Ingredients often used in OTC cold meds | Decongestants (pseudoephedrine, phyenlephrine), Antitussive (dextromethorphan), Antihistamines (diphenhydramine, chlorpheniramine, brompheniramine), Expectorants (guaifenesin) |
| Adverse effects of decongestants (pseudoephedrine, phyenylephrine) | tachycardia, restlessness, insomnia, anxiety, tremors, hypertension, irritability, anorexia, lethargy, headaches, dysrhytmias, hallucinations, dystonic rxns, seizures |
| Adverse effects of antitussives (dextromethorphan) | constipation, dizziness, drowsiness, N/V, depression, apnea, palpitations, possible serotonin syndrome with SSRIs |
| Adverse effects of antihistamines | anticholinergic toxicity; drowsiness, headache, dry mouth, dry eyes, paradoxic exictability, respiratory depression, hallucinations, tachycardia, arrythmias |
| Adverse effects of expectorants (guaifenesin) | nausea, diarrhea, dizzines, headache |
| Complimentary-Alternative Medicine: Herbals | little FDA regulation, difficult to determine toxicity due to lack of standards |
| How much Ibuprofen can lead to toxic levels? | >400mg/kg doses |
| Ibuprofen toxicity signs | N/V, epigastric pain, drowsiness, lethargy, ataxia |
| Serious complicatons of Ibuprofen toxicity | renal failure, coma and seizures are rare |
| Treatment of Ibuprofen toxicity | activated charcoal, supportive care |
| What to monitor in Ibuprofen toxicity | renal function and acid-base status |
| Iron ingestion sources | prenatal vitamins, iron supplements |
| Pathophysiology of iron toxicity | corrosive to gastric mucosa and intestinal mucosa, causes mitochondrial/cell dysfxn, capillary leak lead to hypotension |
| What is the toxic dose of elemental iron? | >50mg/kg dose |
| How much iron causes just GI symptoms? | >20mg/kg |
| Phases of iron toxicity (IRON acronym) | 1. Indigestion, 2. Recovery, 3-4. Oh my Gosh!, 5. Narrowing |
| Phases of iron toxicity- Phase 1 | GI stage (30min-6hrs): N/V, diarrhea, abd pain, hematemesis, bloddy diarrhea |
| Phase 2 of iron toxicity | Stability for 6-12 hrs |
| Phase 3 of iron toxicity | Systemic toxicity (within 48hrs): CV collapse, severe metabolic acidoses- high Anion Gap (MUDPILES) |
| Phase 4 of iron toxicity | Hepatic toxicity (2-3 post ingestion)- hepatic failure |
| Phase 5 of iron toxicity | GI/pyloric scarring seen in 2-6wks post ingestion. |
| How do you diagnose iron ingestion? | Xray- however, liquid preps and chewable vitamins are not visible. Serum levels. "Vin rose" urine is an unreliable indicator. |
| When do you obtain serum levels for iron overdose management? | 4hrs post ingestion |
| What are the important serum levels for iron toxicity? | <300mcg/dL: minimal toxicity; >500mcg/dL: severe toxicity |
| Treatment of iron toxicity | deferoxamine (IV)- chelation therapy in moderate to severe symptoms regardless of drug levels |
| other treatments for iron toxicity | whole bowel irrigation, endoscopic pill removal |
| What NOT to use with iron toxicity | Ipecac, gastric lavage (large tabs), activated charcoal- does not bind iron, oral bicarb, oral deferoxamine |
| Opiates- examples | morphine, heroin, methadone, propoxyphene, codeine, meperidine |
| Opiate toxicity symptoms | drowsiness to coma, mood change, decreased GI motility, analgesia, N/V, respiratory depression, abdominal pain (due to inc colonic and biliary tone) |
| Opiate overdose signs | Miosis, resp depression, coma, decreased GI motility, hypotension from histamine release, NO change in HR |
| Opiate poisoning signs | respiratory and CNS depression with pinpoint pupils |
| Salicylate- sources | Aspirin, Oil of Wintergreen, antidiarrheal products (Pepto Bismal) |
| Salicylate action | uncouples oxidative phosphorylation |
| Salicylate- toxic dose | >150mg/kg |
| Acute signs of Salicylate poisoning | N/V, tinnitus, hyperventilation- resp alkalosis (not always though), dehydration and hypokalemia --> metabolic acidosis |
| Serious salicylate toxicity | hyperthermia, agitation, confusion, coma, renal failure. Death from pulmonary or cerebral edema, electrolyte imbalance, CV collapse. |
| Monitoring salicylate toxicity | serial levels q2-4hrs: ABG, electrolytes, and Coags |
| Treatment of salicylate toxicity | activated charcoal (drug may form a bezoar in stomach)- consider mult. doses; agressive fluid rehydration; replace bicarb and K; raise urine pH with IV bicarb (enhanced exretion); hemodialysis |
| TCA- tricyclic antidepressants toxicity onset | symptoms within 2hrs, major complications within 6hrs |
| TCA- symptoms of toxicity | CNS effect more prominent in children- lethargy, agitation, seizures, coma; CV- tachycardia, hypertension, hypotension, ECG changes |
| ECG change in TCA toxicity | widened QRS and prolonged QT, multiple differnet cardiac defects may occur late |
| TCA- toxicity symptoms: triC A | Coma, Convulsions, Cardiac dysarhythmias, Acidosis |
| Workup of TCA ingestion: | BMP (hypokalemia), ABG, ECG, urine pregnancy test, urine drug screen for co-ingestion |
| Danger of perscribing TCA | ingestion of younger sibling |
| Treatment of TCA overdose | ABCs, activated charcoal/gastric lavage, alkalinize serum with sodium bicarb (pH 7.45-7.55) prevents dysrhythmias, ECG monitoring |
| Treatment of dysarrthymia from TCA overdose with | lidocaine (use of phenytoin is controversial) |
| DO NOT tx TCA overdose with | ipecac (risk of aspiration) or physostigmine |
| What are your environmental toxins? | Carbon monoxide, caustic agents, esophageal foreign bodies, hydrocarbons, ethanol, ethylene glycol, organophosphates, and plants |
| Carbon Monoxide- what is it? | colorless, odorless gas- car in the garage with the engine on, space heater in an enclosed home |
| Action of carbon monoxide | CO binds reversibly to one of Hgb 4 binding sites, this "carboxyhemoglobin: impairs oxygen release at the other 3 sites. This shifts the dissociation curve to the left. O2 carrying capacity and availability to the tissues is impaired |
| Symptoms of carbon monoxide poisoning | headache, dizziness, nausea, malaise (Flu like symptoms). Visual changes, weakness, syncope, vomiting, ataxia, seizures, coma, and death. Cherry red skin is not of diagnostic value. |
| Labratory finding in carbon monoxide poisoning | Carbon monoxide concentration, note: pulse ox will most likely be normal. |
| Carbon monoxide poisoning treatment | Oxygen- high flow mask, immediately, Cardiac monitoring, Correct any anemia, treat metabolic acidosis, ?use of hyperbaric therapy (pregnant and neonatals may benefit) |
| House fire, chemicals that can poison | Carbon monoxide and cyanide |
| What is the half-life of carbon monoxide? | 5hrs in room air, 30-90 minutes on 100% Oxygen. |
| Caustic agents can be alkali or acidic | household items |
| Alkali products in the home- tasteless | oven cleaner, drain cleaner, hair relaxer, bleach, automatic dishwasher detergent |
| Household bleach (5%) | usually only a mild irritant alkali |
| What type of necrosis do alkali products make? | liquefaction necrosis- severe and deep |
| Acidic products in the home- bitter | toilet bowl cleaner, grout cleaner, rust remover, metal cleaners (gun bluing) |
| What type of necrosis do acidic products make? | coagulation necrosis- superficial because mucosa is resistant |
| Hydrochloric acid or sufuric acid are unique in that | they can cause severe gastritis without significant oral or esophageal burns |
| Caustic agents- s/s ingestion | drooling, refusal to drink, vomiting, oral burns, dysphagia, stridor/resp distress, chest or abd pain, hypotension, metabolic acidosis, DIC |
| If there are no oral lesions | you can still have severe esophageal or stomach injury |
| If there are no symptoms with a Caustic ingestion | = little or no injury |
| Caustic ingestions workup | cbc, lytes, BUN, creatinie, CXR, AXR |
| Caustic ingestions treatment | remove contaminated clothing/rinse, early intubation for resp distress or stridor, acutely dilute with water or milk, IVFs, analgesia, upper endoscopy, observe for complications, steroids are usually not helpful |
| When do you want to do Endoscopy in a caustic injuries case? | in 12-48hrs if there are severe oral burns or symptoms |
| DO NOT do this with caustic injuries | neutralize, induce emesis. NO gastric lavage or activated charcoal. |
| Burn complications of caustic injuries | necrosis, esophagitis, perforation, late stricure formation |
| Complications specific to Hydrochloric/Sulfuric acids | severe gastritis, perforation or peritonitis, late stricture.... all without severe mouth or esophageal burns!!! |
| Esophageal foreign bodies commonly occur in what age? | 6mo to 3yo |
| Most common esophageal FB | coin |
| Lodging places in the esophagus | upper esophageal sphincter, aortic arch, lower esophageal sphincter |
| S/S esophageal foreign bodies | 30% asymptomatic; drooling, dysphagia, choking, gagging, vomiting, cough, stridor, wheeze, dyspnea. pain in neck/throat/chest |
| Coin flat on AP film, location? | located in esophagus |
| Coin on edge on AP film, location? | located in trachea |
| When is endoscopic removal necessary? | urgently if respiratory symptoms, sharp object, button batteries, no movement past LES in >24hrs |
| Other methods of detection of FBs | CT scan, contrast esophagram, or metal detectors |
| Other methods of removal of FBs | balloon catheter under flouroscopy, push into stomach using bougie dilator |
| Button Batteries- what's the danger? | needs immediate removal due to caustic leakage and electrical current can cause burns, can get mucosal injury in 1hr, full thickness injury in 4hrs |
| Radiographic finding of button battery | double ring |
| What do you do if a button battery is in the stomach? | monitor stools, repeat xrays q3days |
| How dangergous is a button battery in the nose or other orifice (ear canal)? | Same danger as esophagus- needs immediate removal. |
| Ethanol- what products are in the home? | Besides liquor cabinet, mouthwash, perfume, vanilla extract for baking |
| Ethanol- what is the danger in young kids <5yo? | Hypoglycemia: ethanol inhibits hepatic gluconeogenesis leading to hypoglycemia in 10-22% in <5yo. Its the kid who is in hypoglycemic crises the morning after his parents had a party. |
| Ethanol signs and symptoms | CNS depression (esp in young kids), N/V, slurred speach, ataxia, resp depression, seizures, coma, hypothermia |
| Ethanol ingestion- diagnosis | Ethanol level, Increased osmolar gap (>10 gap identifies unknown alcohol ingestion) |
| Treatment of ethanol intoxication | ABCs, IVFs, treat hypoglycemia and hypokalemia, hemodialysis is rare, rewarm |
| Do you use activated charcoal for ethanol ingestion? | Not for ethanol ingestion alone, consider if necessary for another substance that was co-ingested. |
| What can happen when there are other co-ingestions with Ethanol? | Toxicity from other substances can be masked by the symptoms of toxicity from ethanol ingestion.... always screen for others. |
| What is Ethylene Glycol? What is the toxicity? | antifreeze found in radiator fluid and coolants, it tastes sweet. Metabolites are toxic. |
| What are 3 stages of Ethylene Glycol toxicity and when do they occur? | Stage 1 (1-12hrs): N/V, drowsiness, slurred speech, lethargy. Stage 2 (12-36hrs): tachypnea, cyanosis, pulmonary edema, ARDS, death. Stage 3 (2-3days): cardiac failure, seizure, cerebral edema, RENAL FAILURE |
| How do you diagnosis Ethylene Glycol toxicity? | Increased osmolar gap (>10 identifies unknown alcohol ingestions), Increased anion gap (>12 MUDPILES), urine may flouresce under Woods lamp. |
| Treatment of Ethylene Glycol toxicity | Gastric decontamination (not charcoal), Na Bicarb for metabolic acidosis, IV calcium for symptomatic hypocalcemia. Consider Antidote. Consider hemodialysis if severe. |
| Antidote for Ethylene Glycol toxicity | IV ethanol or Fomepizole (fewer side effects, easier dosing but costly) |
| What are hydrocarbons and what makes it toxic? | kerosene, gasoline, lamp oil, mineral spirits, some pesticides. Low viscosity fluid that leads to pulm aspiration. Metabolite carbon tetrachloride is liver toxic. Inhaled propellants- refigerants, toluene can sensitize to cardiac arrythmias. |
| What are the clinical finding of hydrocarbon ingestion? What are the lab findings? | coughing, choking, gagging, tachypnea, wheezing, resp distress, mild CNS depression, fever. Lab findings are leukocystois, CXR may have 24hr delay in findings. |
| Treatment of Hydrocarbon ingestion: | Dermal decontatmination (remove clothes, wash skin), observe for at least 6hrs. If symptomatic then supprotive care, airway control and ARDS treatment. |
| What not to do in Hydrocarbon ingestion: | Ipecac, gastric lavage- except with very large or very toxic ingestion, activated charcoal, steroids, prophylactic abx, epinephrine (v-fib) |
| Where would you have Organophosphate exposure? | Pesticides on a farm that contain diazinon, malathion. Bioterroism attack? |
| What is the method of action for organophosphate and recovery potentional? | Bonds permanently to cholinesterase leading to excess acetylcholine for 2-3 days. It takes weeks to months to regenerate enzymes |
| Organophosphate toxicity signs are for cholingeric crisis: DUMBELS | Diarrhea, Urination, Miosis, Bronchorrhea/Bronchspasm, Emesis, Lacrmiation, Salivation |
| What are the other signs of organophosphate toxicity (nicotinic effects + others) and what is specific to kids. | Nicotinic effects: Twitching, Weakness, Resp weakness. Confusion, coma, convulsions, slurred speech. Kids are more likely to present with AMS and muscle weakness (which is not your classic cholingergic crisis) |
| What show up on labs for organophosphate toxicity? | decreased RBC cholinesterase activity confirms diagnosis |
| How do you treat organophosphate poisoning? and the health care workers helping a victim? | protect all caregivers with protective clothing (surgical mask and latex gloves are not effective). ABCs, decontaminate clothing and skin, Antidote, Benzodiazepine for CNS symptoms. May require weaks of treatment. |
| What is the antidote for organophosphate? | Atropine- large dose and may need repeated doses. Pralidoxime (2-PAM)- use with atropine, works before bond ages. |
| Resource for plant exposure toxicities. | Poison control |
| Side effects of this plant: Peace lily | GI irritation and burning |
| Side effects of this plant: Pokeweed | irritation of skin and GI tract |
| Side effects of this plant: Dieffenchachia, philodendron (houseplants) | oral pain |
| Side effects of this plant: poinsettia, mistletoe, holly | mild GI symptoms |
| Side effects of this plant: foxglove, oleander, lily of the valley | digitalis-like toxicity |
| Side effects of this plant: Jimson weed, Angels trumpet | anticholingeric poisoning |
| Side effects of this plant: lethal mushrooms | delayed symptoms- liver toxicity |
| What animal bites are a concern for Rabies? | bat, raccoons, skunk, foxes (major carriers). Sometimes Dogs and Cats are reservoirs. |
| What animal bites are NOT a concern for Rabies? | Rodents: squirrels, rabbits, rats |
| What is considered Bat exposure? | bite, exposure to fluids, founds sleeping in a room with a bat, bat in close proximity to a child. |
| What do you do with the domestic vs wild anmial when you are concerned about Rabies? | observe the domestic animal, euthanize if becomes ill. Euthanize all wild animals for testing (brain is source for testing). |
| What is Rabies therapy? how do you give? | HRIG (Rabies Immune Globin)- inject as much as possible into the wound, the rest is given IM. Rabies vaccine- 4 doses on Day 0, 3, 7, and 14 (do not give in gluteus). |
| What is the most common type of snake bite? | 95% are Pit viper (rattlesnakes, cottonmouths, and copperheads)- triangular head, elliptical eyes, pit between eye and nose. |
| What does Pit viper vemon do? | cause tissue necrosis, vascular leak, coagulopathies and neurotoxicity. Children are susceptible due to low body mass. s/s develop in 2-6hrs with severe pain, N/V, weakness, muscle fasciculations, coagulation abnormalities. |
| What is the treatment of Pit viper vemom? | ID the snake (?antidote). Immobilize extremity and apply wound pressure (DO NOT ice or "suck and spit"). IVFs, pain meds. Give tetanus booster if needed (Tdap if >7yo, DTap if <7yo). |
| Describe a Black Widow spider and where are they found? | Red/orange hourglass markings on the abdomen. Found in barns, woodpiles and nests. |
| What are the symptoms of Black Widow spider bite and how do you treat? | pain around site, muscle cramping, chest tightness, vomiting, malaise, sweating, abdominal pain (mimics appy or MI), agitation and hypertension. Treat pain, benzodiazepines, antivenom in severe cases, IV calcium is ineffective. Resolves in 24-48hrs. |
| Where is a Brown Recluse spider found and what is the hallmark lesion? | basements and attics. Venom causes an ulcer due to lyses of cell walls. Think "U" in ReclUse=ulcer. |
| What are the symptoms of Brown Recluse spider bite and how do you treat? | initially painless then pain around the site, hemorrhagic blister to large ulcer. Systemic symptoms (fever, chills, N/V) are rare but admit for these. Otherwise provide hydration and local wound care. |
| What is the most common spider bite? | MRSA- trick question, not really a spider |
| What is the 2nd major cause of unintentional pediatric death? | burns |
| What types of burns are there? | fire, scalds, flame, electrical, chemical |
| What percentage of burns are due to abuse? | 18% |
| Some safety tips to prevent burns? | keep matches out of reach, electrical plug protectors, fireworks safety, set water heater to 120 F |
| Burn First Aid | Extinguish flames, ABCs, remove clothing, wash off chemicals, cover burn with clean dry sheet- apply cold/wet compressess (careful with large burns and a small child- can get hypothermic). Do not apply grease, butter or ointment. |
| Burn classification: superficial redness, minor swelling, pain, resolves in 1 week | First- degree |
| Burn classification: blisters or blebs, redness, painful, tissue underneath still perfused, takes 1-3 wks to heal | Second- degree |
| Burn classifcation: dry, leathery, waxy, no pain, requires grafting or healing from edges in small burns | Third- degree |
| Burn Surface Area- Rule of nine (>9yo) | Head and neck total 9%, Each upper limb total 9%, Thorax and abd front 18%, Thorax and back 18%, perineum 1%, each lower limb total 18% |
| Burn Surface Area- Rule of palm (<9yo) | use in small burns, child's palm (not including fingers) = 0.8-1% BSA |
| Minor Burn Care: First-degree | pain control |
| Burn Care: partial thickness burn | clean with soap/water daily, leave blisters intact- debride when ruptured, Abx ointment (silver sulfadiazine or bacitracin), pain control, update tetanus, re-evaluate every 2-3 days- burn can progress, avoid sunlight |
| Do you need to cover Facial burns? | No, they may be left open to heal |
| Burn Care: major burns | ABCs- consider carbon monoxide or cyanide poisoning, IVFs if >15% BSA, pain control |
| What is the Parkland formula for IVFs in burn managment? What fluid do you use? | 4mls/kg/%burn first 24hrs (burn has 4 letters). Use Ringers lactate. 1/2 volume in first 8hrs, the rest in next 16hrs. Add MIVFs rate to this volume. |
| How much fluid for a 10kg child with 20% burn? | 4mL/kg/%burn = 4x10x20= 800mL. Give 400mL in first 8hrs, then 400mL over next 16hrs. Add this on top of MIVFs. |
| When do you refer a burn? | >15% BSA, full thickness burns >2%, inhalation injury, larger burns of hands/feet/face/perineum, concern for abuse |
| When are minor electrical burn injuries concerning? | Extension cord bite injuries must be referred to a burn surgeon due to oral commissure burns. Superficial burns may otherwise just require cleaning and abx cream. |
| What to do with high-tension electrical wire burns? What is the injury and why the concern? | Admit all, they are serious due to concerns for deep-muscle injury, arrhythmias, seizures, brainstem paralysis, ocular damage, fractures and renal failure. You may have little surface damage with deep-tissue burns. |
| Who drowns- biggest age group and gender? Where do they drown? | 40% <5yo, M>F. Bathtubs, pools, open bodies of water. |
| How can you prevent drowning? | sourrounding stand-alonge fencing, self-closing gates, locked gates, pool alarm, pool cover, close supervision (even at a party) |
| Pathophysiology of drowning and how much time do you have? | Laryngospasm when you swallow water, LOC, Vomiting/aspiration in 90%, hypoxia/terminal apnea, circulation fails in 3-4minutes, CNS injury in 3-5minutes |
| Near drowning most common cause of death? | CNS injury- hypoxic ischemic injury (cerebral edema) with hyperglycemia exacerbating brain injury |
| Freshwater vs Saltwater drowning managment? | managed the same way |
| Hypothermia in a near drowning victim- when is it protective? | Survivors (10-150min) drowned in freezing water (<5 C) and had a core body temp of (<30 C/ 86 F). Note cold water that isn't icy is NOT protective. |
| Complication of pulmonary aspiration in a near drowning victim? | aspiration is usually small but can cause ARDS or pulmonary edema |
| Near drowning treatment | ABCs, protect c-spine if a diving injury or abuse, apply cricoid pressure- vomiting is common, NG tube, warmed IVFs and O2, warmed gastric/bladder lavage. |
| What core temperature must be obtained in a freezing-water drowning vicitim? | resuscitate until core temp is 32 C |
| How long do you observe near-drowning victims? | >12 hrs because you may have an initial recovery period followed by ARDS (resp s/s develop by 8hrs) |
| What else is associated with an adolescent who has a head injury? | drug and alcohol abuse |
| S/S head injury, | vomiting, lethargy, headache, irritability, behavioral changes, altered mental status (GCS), scalp swelling/??stepoff, pupillary changes |
| Basilar skull fracture signs | Raccoon eyes (bruising under the eyes) & Battle's sign (postauricular bruise) take hours to develop. Also hemotympanum, hearing loss, facial paralysis, CSF otorrhea |
| When does papilledema develop in a head injury? | hours to weeks, it is a late sign of intracranial hypertension |
| What to think in an infant with retinal hemorrhages. | ABUSE- shaken baby, there does not have to be significant external signs to have a significant brain injury |
| What is Cushing's triad? | impending herniation causes bradycardia, irregular respirations and hypertension. |
| What is the best modality for studying intracranial contents in a head injury? | CT w/o contrast |
| Who do you CT in a head injury? | evidence of skull fx, altered level of alertness, neurologic deficit, persistent vomiting, presence of scalp hematoma, abnormal behavior, coagulopathy |
| Skull radiographs may benefit (less radiation) in | minor head injuries, palpable depression, Battle's sign, hemotympanum, infants |
| When do you intubate in a head injury case? | GCS <8 |
| Treatment of head injuries | ABCs, control C-spine, mild hyperventilation, support BP with IVFs, Mannitol/ 3% saline if s/s herniation, CT scan for potential surgical lesions |
| Subdural hematoma- description | bleeding is from bridging veins, blood accumulates in the outermost meningeal layer, between dura mater (which adheres to skull) and the arachnoid mater (which covers the brain) |
| Epidural hematoma- description | blood from tears in arteries with build up of blood between dura mater and skull |
| Signs of concussion | confusion, LOC, vision disturbance, loss of equilibrium, amnesia, headaches, dizziness |
| Neuro exam in concussion | ask about the game vs name and phone number |
| Concussion definition | traumatic alteration in mental status with or without LOC |
| Second-impact syndrome | head injury before full recovery from a previous concussion can cause loss of autoregulation of cerebral blood flow with rapid development of increased ICP. The younger the child the more sensitive to concussion |
| Concussion guidelines | Player MUST be asymptomatic before returning to play. 6 step-wise progression where they get to do a little more each day. |
| Player with LOC <5min, when to return to play | out 1 week after symptom free- follow 6 day step-wise progression |
| Player with LOC >5min, when to return to play | out at least 1 month |
| Multiple concussions managment | longer time for return to play, MRI may be useful in evaluation |
| How do you clean a laceration? | irrigate with normal saline under mild pressure |
| Scalp laceration- can you use top adhesives? | No |
| Who do you call for a complex vermillion border laceration? | plastic surgeon |
| Who do you call for a clenched fist hand laceration? | Hand surgeon, there is a high risk of infection |
| Who do you call for an eyelid laceration if tear duct needs repair? | Ophthalmologist |
| What are the complications of laceration repair? | tendon laceration with loss of fxn, arterial or vascualr compromise, infection (staph, strep or Pseudomonas- nail thru tennis shoe), joint involvement, limited flexibility, cosmetic concerns with scarring or keloid formation |
| Puncture wounds- concerns | high risk for infection and foreign body. May need to Xray, US or CT |
| Treatment of puncture wound | superficial irrigation only, do not repair, prophylactic abx only if dirty wound, update tetanus |
| Growth Plate Fracture classification | Salter-Harris Classifcation |
| Salter-Harris Classification (SALTS) | I Separated, II Above (metaphysis), III Lower (epiphysis), IV Together/thru (metaphysis and epiphysis), V Smashed (compressed growth plate) |
| Which Salter-Harris fxs need Ortho? | III and IV |
| Which Salter-Harris fx is most common? | II |
| Which Salter-Harris fxs are difficult to see on radiograph? | I and V |
| When in doubt about a fracture | splint/cast then repeat xray later to look for healing callous |
| Greenstick Fracture description and prognosis | cortex is fractures on the tension side and there is a plastic deformity on the compression side, fracture is not complete. Heals well |
| Clavicle Fracture- who gets them, common type, injury associated | Common in kids <10yo, 80% are in the middle 3rd portion of the clavicle. Fall on outstretched arm or direct trauma. |
| Clavicle Fracture- diagnosis and treatment | physical exam/radiograph. Sling for comfort x 2weeks. Heals in 3-6wks |
| Buckle fracture | compression of bone produces a torus fracture, most common in distal radial metaphysis. Heals well after 3 weeks immobilization |
| Spiral fracture | curvilinear course, common in toddlers, think abuse if child is not walking |
| What is the most common elbow fx? | Supracondylar Fracture |
| Method of injury in a distal humerus fx? | fall on outstretched hand or elbow, monkey bars |
| Complication in Supracondylar fx of the humerus? | brachial artery, median nerve or radial nerve damage in a displaced fx. Monitor neurovascular status closely. |
| Radiographic sign in an elbow fx? | Posterior fat-pad |
| Complication in tibial fx? | Compartment syndrome (swelling and vascular injury lead to ischemia). This is an emergency. |
| Compartment Syndrome signs | pain out of proportion to the fracture, pulses may be normal, pain remote to fracture site. This is due to compromised tissue blood flow. |
| Gait disturbance in a young kid, occult fx not evident on radiograph, what do you do? | Treat as if fractured and repeat radiographs- signs of healing fx will show up. |
| Subluxation of the Radial Head term, age and mechanism of injury | Nursemaids elbow, 6mo-5yo, occurs due to traction on a pronated wrist- annular ligament slides over the radial head. |
| Nursemaids Elbow- exam and treatment | Extrimity is held limply to the side, no TTP at elbow but pain with elbow movement. DO NOT Xray. Reduce by supination of the forearm with flexion at the elbow (or pronated the foreamr). Return to fxn in 15min. |
| Athlete/Teen falls on adducted shoulder and has tenderness over the AC joint, what injury? | Acromioclavicular separation |
| Shoulder is swollen with deformity anteriorly, what injury and what is best imaging? | Dislocated shoulder- best seen on Y view of shoulder radiograph, rare in prepubertal kids- they usually fx |
| How do you treat a shoulder dislocation? | pain control first then traction/countertraction, sling and swathe |
| Sprain in a 5yo | most likely a fracture- ligaments are stronger than growth plates in these little ones |
| Common sprains in older children | ankle and finger |
| Uncommon sprains in older children | wrist and elbow |
| Treatment of ankle sprain based on severity | Grade 1: rest 7-10days, Grade 2: 2-4wks, Grade 3: 5-10wks |
| Severe lateral malleolus tenderness- what should you think of | Salter Harris 1 fracture |
| Fussy infant | corneal abrasion- check w/ fluorescein dye and a slit lamp or Woods lamp |
| Signs and treatment of corneal abrasion | pain, tearing, photophobia, decreased vision. Tx with topical abx ointment, topical pain drops (cycloplegic- in office only) |
| How do you handle a penetrating globe injury in the field? | protect eye with a styrofoam cup, minimal manipulation, call ophtho |
| Hyphema, what does it look like and what to do? | presence of blood in anterior chamber of the eye from blunt of perforating injury. Tx with bed rest but elevate head to 30-45 degrees. |
| Kid hit in the eye with baseball (or other blunt trauma), now has limitation of upward gaze. | fracture of the orbital floor with eye muscle entrapment |
| Chemical (alkali or acidic) burn to cornea, how long to irrigate with NS? | Mild case: 30min or 2L NS, Severe case: 2-4hrs or 10L NS, CHECK OCULAR pH |
| Chemical burn to the eye, now has corneal opacification- what kind of chemical? | Alkali |
| Mild acid or alkali burn to the eye causes | mild corneal erosions |
| (PALS) Establishing an airway- same no matter what age | head tilt/chin lift, jaw thrust if trauma |
| (PALS) Choking infant | back blows and chest thrusts |
| (PALS) Choking child/adolescent | abdominal thrusts |
| (PALS) Initial breaths- no matter what age | 2 breaths |
| (PALS) Breathing rate/ No CPR, infant and child | 12-20 breaths/min |
| (PALS) Breathing rate/ No CPR, adolescent | 10-12 breaths/min |
| (PALS) Breathing rate when doing CPR, no matter what age | 8-10 breaths/min |
| (PALS) Where do you check for circulation? | Infant: brachial or femoral, Child/Adolescent: Carotid |
| (PALS) CPR technique- infant | 2 thumbs w/ encircling hands at lower 1/2 of sternum |
| (PALS) CPR technique- child and adolescent | heel of one hand, other hand may be on top |
| (PALS) Rate of chest compressions- no matter the age | 100/min |
| (PALS) Ratio of breaths to compressions- infant and child | 15:2 |
| (PALS) Ratio of breaths to compressions- adolescent | 30:2 |
| Pediatric Bradycardia with a Pulse- no CV compromise | ABCs, O2, observe |
| Pediatric Bradycardia with a pulse, HR<60 and CV compromise | ABCs, O2, CPR, Epinephrine- repeat q3-5min. Atropine (0.02mg/kg- min dose of 0.1mg), may repeat. Continue CPR |
| Pediatric Pulseless Algorithm: V-fib or V-tach | Shock 2J/kg, Shock 4J/kg, Epinephrine, Shock 4J/kg, Amiodarone/Lidocaine (repeat) |
| Pediatric Pulseless Algorithm Asystole/PEA | CPR, Epinephrine- repeat every 3-5min |
| Epinephrine dose IV or IO | 0.01mg/kg |
| Epinephrine dose for endotracheal tube | 0.1mg/kg |
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