CMC COMPENDIUM
  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction

Toxic Alcohols - Dr. Snow

12/3/2015

0 Comments

 
Picture
  • ​Always include toxic alcohols in your differential of anion gap metabolic acidosis.
  • K.I.L.R for acidosis: Ketoacids, Ingestion, Lactate, Renal 
  • Toxic alcohols in 3 easy steps: R.B.D. = Recognize the diagnosis, Block ADH, Dialysis when needed
  • Know how to calculate the osmolar gap  (Measured osm - Calculated osm)
  • Calculated osm = 2xNa + BUN/2.8 + Glucose/18 + ETOH/4.6
  • Must be drawn at same time as BMP
  • Do not wait on alcohol levels to institute alcohol dehydrogenase blocking therapy
  • Ethanol and Fomepizole appear to be equally efficacious as antidotes.  However, ethanol infusions have a much higher adverse event rate.
  • Ketosis/ketouria, osm gap, withOUT metabolic acidosis = isopropyl alcohol
  • High dose lorazepam or diazepam infusions: remember propylene glycol——lactic acid can produce acidosis.

0 Comments

Child Abuse & Toxins - Dr. Beuhler

10/1/2015

0 Comments

 
Picture
·         Consider poisoning when confronted with confusing clinical presentations

·         Always
save and freeze initial urine from suspicious cases

·         “Munchausen’s by proxy” is now known as “Factitious disorder imposed on another” or “child abuse” and does not require exotic toxins.



0 Comments

Snake Bites - Dr. Kallgren

8/27/2015

0 Comments

 
Picture
  • Epidemiology: vast majority of snake bites are from nonvenomous snakes, fatalities extremely rare
  • Crotalids (vipers) have hemotoxic venom, Elapids (cobras) have neurotoxic venom
  • Six venomous species in North Carolina, five are vipers so treated with CroFAB

Field treatment: don’t make things worse, get to the nearest hospital

In the hospital:                 

1.     ABCs
2.     Wound assessment and pain control
3.     Labs to assess for coagulopathy and rhabdomyolysis
4.     Call poison control – should always talk to toxicologist
5.     CroFAB vs observation only

                                      - Mild/dry bite: no CroFAB, just observation
                                      - Moderate/severe: one or more doses as needed based on wound progression

CroFAB is only curative treatment currently but VERY expensive; Currently evaluating anti-TNFa agents

TNFa pilot study: active now, enrolling nonpregnant healthy adults



0 Comments

Pesticides - Dr. Buehler

8/7/2014

0 Comments

 
Picture
Organophosphates
  • DUMBBBELLS  - Diarrhea, Urination, Miosis, Bronchorrhea, Bronchospasm, Bradycardia, Excitation, Lacrimation, LOTS of Emesis, Salivation
  • Can have persistant symptoms that can happen days after initial exposure 
  • Intermediate syndrome - develop days after exposure
  • Chronic symptoms - neuropsychiatric changes 
  • Treatment - remove exposure!!!
  • Muscarinic antagonist/ blockers; anticholinergics
- Atropine - MUCH higher doses than normal
- Valium
- Restore acetylcholinesterase enzyme - 2PAM - bolus then infusion

0 Comments

Drug-Induced Hyperthermia - Dr. Kerns

7/3/2014

0 Comments

 
Picture

Mechanisms of hyperthermia
  • Hurt the hypothalamus or mess with NT
  • Increased muscle activity
  • Vasoconstriction
  • Uncoupling cellular respiration

Malignant Hyperthermia

   - Rare
   - Increased peripheral muscle activity due to ryanodine receptor issues - genetic component
   - Only seen with anesthesia - halothane, succinylcholine
   - Fast onset from exposure, severe and short lived - hyperK, muscle rigidity, autonomic instability,
   - increased CO2 on capnography


Neuroleptic Malignant Syndrome

   - Due to altered DA transmission - seen with typical antipysch meds, lithium, environmental (heat)
   - Subacute, severe, lasts day-weeks
   - Lead pipe rigidity, autonomic instability, AMS


Parkinsons Disease
   - abrupt withdraw of DA agonist therapy can cause hyperpyrexia



Cocaine/ Stimulants
  - Hypothalamic stimulation, vasoconstriction, increased muscle activity
  - Fast onset, short duration, severe hyperthermia


Serotonin Syndrome

   - Increased central 5HT activity
   - More common in drug drug interactions - SSRI/SSRI or SSRI & other serotonin agonists - TCA,
     demerol, linezolid, MAOI, tramadol, dextromethrophan (MAOI activity)
   - Subacute, moderate severity
   - AMS, muscle rigidity (LE>>UE), hyperreflexia & rigidity, autonomic instability

   - NBOME - designer drugs - increased serotonin activity


OTHERS:
Anticholinergic

   - increased muscarnic blockade
Salicylate toxicity

   - uncouples cellular respiration
Baclofen withdraw


Complications from hyperthermia

  - Resp, PE, rhabdo, hepatic failure, hyperK


Treatments

- DC offending agents or restart withdrawn med
- Physical cooling
- Sedation - benzos, non depolarizing blockade


 - Secondary Treatments
      > Cyproheptadine - serotonin antagonist (for 5HT syndrome) - PO only
      > Dantrolene - for malignant hyperthermia - first line agent
      > Limited evidence for NMS - dantrolene has been tried - don't use as monotherapy
      > Dopamine agonist - bromocriptine, amantadine - dont use as monotherapy (long time to start acting)

     > ECT - unknown mechanism

54000 or 800-222-1222 - poison control


0 Comments

M&M - Dr. Keller

4/10/2014

0 Comments

 
Picture
Central Cord Syndrome
-Generally caused by hyperextension. Patients with history of central canal stenosis at risk
-Upper extremities affected > lower extremities
-Distal affected > proximal
-Usually bladder dysfunction

Opioid Induced Hearing Loss
-Occurs <72 hours after use (seen in both acute and chronic users)
-MCC is hydrocodone and heroin but seeing more with methadone lately
-May be unilateral or bilateral
-Most resolve within 72 hours but may be permanent
-Treat with cessation of narcotics and possibly cochlear implants if permanent

Rhabdomyolysis
-Fluids, fluids, fluids as treatment
-Diuretics (mannitol) and bicarb are controversial
-Risk of AKI is lower when CK <5,000 but can be seen at CK levels of 1,000
-Urine dipstick + for blood with urinalysis - for blood has sensitivity of 80% for diagnosis

0 Comments

Iron - Dr. Beuhler

2/6/2014

0 Comments

 
Picture
Iron

    - Metals in salt form cause VOMITING
    - 2+ ferrous sulfate in absorbable state → 3+ state for storage/transfer

Chewable tablets
    - 10-18mg/tab
    - Hard to overdose on these - “minimally toxic”

Iron carbonyl
    - elemental iron
    - low toxicity

Iron filings in hand warmers → if ingested, could be toxic

Prenatal vitamins
    - greatest morbidity
    - look like candy

  • When considering overdose, must calculate the dose of elemental Fe ingested
  • Varies based on the substance, so just look up -- or Call Poison Control!
  • Toxic dose starts at 20-60mg/kg
  • >60mg/kg -- concern 
  • If no vomiting associated, probably ok and not at toxic level

Injuries
  • GI -- mucosal damage, ulceration, perforation, hemorrhage, strictures
  • CV -- decreased cardiac contractility, vessel injury, 3rd spacing of fluid
  • Liver -- a hepatotoxin -- periportal necrosis, sequestered in 1st pass metab, coagulopathy, hyperammonemia, hypoglycemia


5 stages of toxicity

1. ingestion to 6h

    - vomiting!!
    - abd pain
    - diarrhea
    - melena/hematemesis
    - bowel wall necrosis/infarct

2. 6h - 24h

    - quiescent stage
    - symptoms appear to resolve
    - continued worsening acidosis
    - if ingestion was small → course usually stops here
    - if ingestion was large → this stage is sometimes skipped and go onto more badness

3. 12h - 48h

    - crash
    - CV, Liver, GI, ARDS, CNS lethergy/coma, Acidosis

4. 2d - 3d

    - independent of severity of stage 3
    - fulminant hepatic failure
    - >1000 iron level

5. weeks later

    - mucosal injuries/strictures

Iron Levels
  • Iron levels peak around 2-6 hr, longer if enteric coated tablets
  • Level not a reliable indicator of toxicity
  • 300-500 -- systemic toxicity
  • >500 → treat
  • Get a level before started deferoxamine

Workup


   - electrolytes -- AGMA
   - coags if bleeding
   - LFTs if sick
   - APAP level for intentional ingestion -- think about synergy

   - x-rays -- abd → see pills sometimes

Management

  • obs for 6 h if asxs → ok → home
  • no GI or acidosis
  • if sxs, esp GI or acidosis → admit for obs
  • get iron level
  • fluid resuscitation
  • no lavage/charcoal/ipecac/bicarb
  • may consider whole bowel irrigation if positive xray
  • Deferoxamine
  • specific antedote for iron
  • no heme/cytochrome iron binding

        use:

            hx of sxs, pos xrays, super high iron level
            100mg binds 10mg iron

        IV admin -- 15mg/kg/hr for rate but may not get in enough

        Side Effects:

            hypotension, tachycardia, diuresis

            visual/ototoxicity, abd pain, fever, diarrhea

            increased risk for yersenia enterocolitica sepsis

        stop when acidosis resolves

Core Concepts:


    elemental dose is what’s toxic

    no charcoal for tx

    look for anion gap metabolic acidosis

    check an xray for pills, but if it’s negative doesn’t mean pt isn’t sick

    there’s a quiescent phase of toxicity

    deferoxamine is an option for iron chelation

    pay attention to units used to quantify iron --usually in dL


       


0 Comments

M&M - Dr. Zahn

1/23/2014

0 Comments

 
Picture
Dens fracture

      > Type I: Extends through the tip of the dens

      > Type II: Extends through the base of the dens - unstable

      > Type III: Extends through vertebral body of axis - can be unstable

Geriatric Trauma

   - Falls - leading cause of injury

   - Frequently fail to mount a tachycardic response


TB meningitis

  • 1% of all cases of TB
  • Subacute meningitis illness
  • Difficult to differentiate early in the course. 
  • Gradual onset of headache, increasing confusion, malaise & insomnia
   > CSF - high opening pressure, leukocytosis with lymphocytic predominance, elevated protein, low glucose

   > If lymphocytic meningitis, likely not viral if low glucose - LOW GLUCOSE IS NOT NORMAL FOR VIRAL MENINGITIS

   > Absence of fever doesn't exclude TB

   > Cranial nerve 6 = most common nerve palsy in meningitis


Chronic Acetaminophen Toxicity

      - Can't use nomagram with chronic ingestions

      - NAC - replenished and maintains glutathione stores - also thought to have a role in free radical scavenging; IV or PO acceptable

      - If unknown ingestion time and LFTs or APAP elevated



0 Comments

Caustic Ingestions - Dr. Ford

1/9/2014

0 Comments

 
Picture
Mechanism of GI injury
Damage is due to multiple factors:
- tissue contact time
- pH and concentration
- ability of caustic to penetrate tissues
- presence of absence of food in stomach
- titratable acid/allkaline reserve (TAR)
            - amount of neutralizer needed to titrate pH of caustic to physiologic pH of tissues
            - higher TARs produce more damaged tissue


Alkalis
- injury is due to LIQUEFACTION NECROSIS - bad because injury keeps penetrating until neutralized or penetration of organ occurs - can get esophageal and gastric injuries

  > Sodium hydroxide
  > Sodium hypochlorite (household bleach) - worry about ingestion of larger amounts or higher concentrations
  > Ammonium hydroxide (toilet bowel cleaner)
  > Household detergents - usually dont cause GI injury but massive ingestions can be bad

Acids
- + ion causes COAGULATION NECROSIS - ulceration and perforation can occur; can get gap or nonanion gao acidosis; both esophageal and gastric injuries as well as pylorospasm


Classification of caustic injury of esophagus

     Grade I - hyperemia
                        - diet as tolerated, early D/C (likely need to be brought in initially for obs)
     Grade II - ulcerations and exudates
     Grade III - necrosis and deep ulcerations

* Be aware - these people can have an initially benign presentation
* Don’t use presence or absence of oral pharyngeal lesions to determine damage distally



Management

- Hydration
- Steroids for airway edema (not research base)
- CBC, lytes, VBG, coags
- Not unusual to have GI bleed early on, but check type and cross
- Airway - manage early (WEAR MASK), get good visualization

- No NG tube for alkali ingestions, but with acid ingestions use w/in 30-60 min, don't do charcoal unless bad ingestion (ex, Zinc Chloride)

- Endoscopy for all intentional ingestions
        - perform in first 12-48 hrs, up to 96 hrs is safe
        - unless they ingest very concentrated products or large amounts - then scope immediately
        - If you do not scope - observe for 6-12 hrs with serial exams and small sips of water

        - Contraindications to endoscopy
                - perforation, supraglottic or epiglottic burns (concern for perforation if you scope)
                - if can’t do endoscopy - perform esophagram and upper GI series 24 hrs after ingestion - use water soluble contrast initially

Sequelae
- scarring
- motility issues
- gastric outlet obstruction
- tracheoesphogeal fistulas
- strictures which SIGNIFICANTLY increases risk for Cancer - need lifelong monitoring

0 Comments

Toxins - Dr. Beuhler

12/5/2013

0 Comments

 
Picture
Cyanide
  • Toxic as a gas or salt
  • Cyanide binds to cytochrome oxidase, blocks aerobic metabolism => lactic acidosis
  • Makes venous blood bright red (not able to extract oxygen)

  • Treatment
    Sodium nitrite - causes metHb, maybe hemolysis
    Hydroxocobalamin - turns all excretions red (this is what we use here)
    Thiosulfate

Carbon Monoxide
  • Common product of incomplete combustion
  • Forms COHb, much greater affinity for Hb than O2
  • Severe exposures cause coma, seizures, cardiac, neuro injury
  • Think about in family with flu-like symptoms, but not fever

  • Treatment
    Get on 100% FiO2
    CO has higher affinity for fetal Hb, be aware of false positives in fetal monitoring
    Evidence is weak for HBO - guidelines say to consider in persistent neuro symptoms >4hrs

Hydrogen sulfide
  • Rotten eggs smell
  • Rapid onset of symptoms
  • Causes olfactory fatigue/paralysis => lose smell sensitivity

  • Treatment
    100% FiO2

Benzonatate
  • Cough suppressant, local anesthetic
  • Tachycardia, CNS sequelae

  • Treatment
    Intralipid, NaHCO3
    IVF, pressors

0 Comments

    Archives

    August 2018
    February 2018
    January 2018
    December 2017
    October 2017
    September 2017
    August 2017
    July 2017
    June 2017
    May 2017
    April 2017
    March 2017
    February 2017
    January 2017
    December 2016
    November 2016
    October 2016
    September 2016
    August 2016
    July 2016
    June 2016
    May 2016
    April 2016
    March 2016
    February 2016
    January 2016
    December 2015
    November 2015
    October 2015
    September 2015
    August 2015
    July 2015
    June 2015
    May 2015
    April 2015
    March 2015
    February 2015
    January 2015
    December 2014
    November 2014
    October 2014
    September 2014
    August 2014
    July 2014
    June 2014
    May 2014
    April 2014
    March 2014
    February 2014
    January 2014
    December 2013
    November 2013
    October 2013
    September 2013
    August 2013
    July 2013

    Categories

    All
    Abdominal Pain
    Abdominal-pain
    Airway
    Back Pain
    Back Pain
    Bleeding
    Change-in-mental-status
    Chest Pain
    Dizziness
    Ecg
    Emboli
    Environmental
    Fever
    Gyn
    Headache
    Hypertension
    Infectious Disease
    Pain
    Pediatric Emergency
    Professionalism
    Psych
    Respiratory Distress
    Sepsis
    Shock
    Toxins
    Trauma
    Vomiting
    Weakness

    RSS Feed

    Tweets by @PedEMMorsels
Powered by Create your own unique website with customizable templates.
  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction