UMEM Educational Pearls

Category: Toxicology

Title: Cyanide

Keywords: cyanide, poisoning, hydroxycobalamin (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Cyanide Presents with arterialization of venous blood (venous blood draw looks like ABG) Reason: o Hemoglobin is not able to offload oxygen o CN poisons cytochrome c oxidase preventing conversion of oxygen to water and thus production of ATP Old antidote: sodium thiosulfate New antidote: hydroxycobalamin binds CN producing cyanocobalamin (Vit B12) When you give it expects a dip in pulse because of its blue color. Remember CN will give you a beautiful 100% pulse all the way to death. Lee J, et al. Potential interference by hydroxocobalamin on cooximetry hemoglobin measurements during cyanide and smoke inhalation treatments. Ann Emerg Med. 2007 Jun;49(6):802-5. Epub 2007 Jan 8.

Category: Toxicology

Title: Tricyclic Antidepressants (TCA)

Keywords: tricyclic antidepressant, electrocardiogram, cardiac toxicity (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Tricyclic Antidepressants (TCA) - Lack of terminal 40msec R wave (R wave in AvR, S wave in I, AvL) means the patient is NOT TCA toxic. - 40msec R wave + QRS >100msec = possible TCA toxicity, treat with NaHCO3 and recheck ECG. - TCA toxicity defined by ECG; if QRS > 100msec, 33% seizures; if QRS > 160msec, 50% v tach Boehnert MT, Lovejoy FH Jr. Value of the QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. N Engl J Med. 1985 Aug 22;313(8):474-9.

Category: Toxicology

Title: Digoxin Toxicity

Keywords: digoxin, cardiac glycoside, toxicity (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Digoxin Toxicity Most common finding on ECG when digoxin toxic: PVCs Most classic ECG in digoxin toxicity: PAT with block Pathognomonic finding (RARE): Bidirectional ventricular tachycardia Easy formula for administration of digoxin specific Fab (Digibind?? or DigiFab?). Remember to round up even if its 2.3 vials, give 3. [(Dig Serum Concentration(ng/mL)) x wt(kg)] / 100 = # vials

Category: Toxicology

Title: Lithium Toxicity Management

Keywords: lithium, renal failure, neurologic (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Lithium Toxicity Management Initial Therapy: 2x maintenance fluid with normal saline Hemodialysis is controversial but will remove lithium quickly Association of permanent neurologic sequelae with elevated lithium level(1) o Looks like a cerebellar stroke 1- Adityanjee. The syndrome of irreversible lithium-effectuated neurotoxicity (SILENT). Pharmacopsychiatry. 1989 Mar;22(2):81-3.

Category: Toxicology

Title: Hyperthermia

Keywords: hyperthermia, serotonin syndrome, neuroleptic malignant syndrome (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Hyperthermia Neuroleptic Malignant Syndrome (Dopamine Inhibition): treat with bromocriptine Serotonin Syndrome (5-HT1A agonism): treat with serotonin antagonist Malignant Hyperthermia (Genetic): treat with dantrolene

Category: Toxicology

Title: Diagnosing Salicylate Toxicity

Keywords: Salicylate, aspirin, ferric chloride (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Diagnosing Salicylate Toxicity - Acute ingestion can initiially present with nausea, vomiting and a respiratory alkalosis - Toxicity defined by an anion gap metabolic acidosis with ketosis and normal glucose - Ferric chloride test (can get from chemistry set): couple of drops into urine, if it changes color to deep purple sensitive positive for presence of salicylate (sensitive but not specific)

Category: Toxicology

Title: Botulinum Toxin

Keywords: botulinum toxin, paralysis, heroin (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Botulinum Toxin Most potent toxin on the planet where 7 picograms IV are lethal to a human Characterized by a descending flaccid paralysis w/o fever bulbar findings 1st Weapon of Mass Destruction but also seen in the IVDA Heroin population Black Tar Heroin outbreak with necrotic ulcers that produced C. botulinum o Most recently in Washington DC 2003 Centers for Disease Control and Prevention (CDC). Wound botulism among black tar heroin users--Washington, 2003. MMWR Morb Mortal Wkly Rep. 2003;52(37):885-6.

Category: Toxicology

Title: Acetaminophen Toxicity

Keywords: acetaminophen, hepatic failure, hepatitis (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Acetaminophen Toxicity Hepatoxicity defined by AST >1000 King s College Criteria to prognosticate hepatic failure and need for transplant: o pH <7.3 o Creatinine >3.4 mg/dL o INR >6.5 o Hepatic encephalopathy Grade III or IV Low phosphate (<1.2 mmol/L) may be predictor of survival and elevated may be indicator of impending hepatic failure. (Especially 48 96 hrs post-ingestion) o Theory is phosphate used in regeneration/healing liver Gow PJ, Sood S, Angus PW. Serum phosphate as a predictor of outcome in acetaminophen-induced fulminant hepatic failure. Hepatology. 2003; 37(3):711.

Category: Toxicology

Title: Toxic Alcohols

Keywords: Ethylene glycol, methanol, toxic alcohol (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Toxic Alcohols Unexplained anion gap metabolic acidosis => give fomepizole (antidote) Hypokalemia, hypocalcemia, elevated creatinine => think ethlylene glycol Visual disturbances => think methanol Ketosis without acidosis and high osmol gap => think isopropanol If osmol gap is >70; high specificity for a toxic alcohol ingestion

Category: Toxicology

Title: Hydrofluoric Acid (HF)

Keywords: hydrofluoric acid, hypocalcemia, burn (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Hydrofluoric Acid (HF) Used in glass etching, brick/porcelain cleaning and available in hardware stores Death has been reported after JUST 2-3% body surface area exposure! Systemic toxicity: hypocalcemia, hyperkalemia and hypomagensemia Local effects: paucity of skin findings with tremendous pain Treatment: skin decontamination, correct electrolyte abnormalities and topical calcium gel for local pain Mayer TG, GrossPI. Fatal systemic fluoride due to hydrofluoric acid burns. Ann Emerg Med 1985; 14: 149-153.

Category: Pediatrics

Title: Leukokoria

Keywords: Leukokoria, white pupil, retinoblastoma (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Leukokoria The White Pupil Leukokoria is seen in 50-60% of the patients with retinoblastoma Retinoblastoma is the most common intraocular malignancy in children, usually detected in the primary care clinic (which the ED often is now) Median age of diagnosis: unilateral = 24 months; bilateral = 12 months Metastatic disease: direct extension to CNS, hematogenous to bones, lung, and brain When detected early, it is one of the most curable childhood cancers Untreated, almost all will die within 2 years Refer anyone without a normal red reflex to an ophthalmologist within 1 week. WG Wilson, JR Serwint. Retinoblastoma. Pediatrics in Review. 2007;28:37-38 Melamud A, Palekar R, Singh A Retinoblastoma. Am Fam Physician. 2006 Mar 15;73(6):1039-44.

Category: Toxicology

Title: Heavy Metal Poisoning Clues for Diagnosis

Keywords: metal, poisoning, thallium (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Heavy Metal Poisoning Clues for Diagnosis Mees lines, indication of arrested nail growth, occurs in lead, arsenic and others Most heavy metals will cause a proteinuria Microcytic anemia and basophilic stippling seen in lead, arsenic, mercury Peripheral neuropathies in otherwise healthy person Thallium causes classic painful paresthesias in lower extremities

Category: Pediatrics

Title: Acute Otitis Media

Keywords: Acute Otitis Media, Amoxicillin, insufflation, Delayed treament (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Acute Otitis Media Make the Diagnosis Properly ==> Acute Onset of Symptoms ==> Signs of Middle Ear Infection (1) Buldging TM, poor mobility c insufflation, otorrhea, air-fluid level ==> Signs of Middle Ear Inflammation (1) TM erythema or otalgia (that interferes with nl activity) Can you wait on the Abx? ==> Older than 6months ==> No severe infections (T>39 C) ==> If yes to both, may hold Abx for 48 hours. Treat Appropriately ==> High-Dose Amoxicillin (80-90mg/kg/D) is 1st line If the decision is made to observe without antibiotic therapy, the parents can be given a prescription for Abx with instructions to fill it if the child does not improve in 48 to 72 hours, or see the PMD in 2 days. (Spiro, D. Tay, K. Wait-to-see prescription for the treatment of acute otitis media. JAMA 2006, 1235.)

Category: Pediatrics

Title: Pediatric Thoracic Trauma

Keywords: Thoracic, Trauma , Traumatic Asphyxia, Pulmonary Contusion (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Pediatric Thoracic Trauma 2nd leading cause of death in Peds Trauma Most injuries in Peds are Blunt Kids are Different ==> More Pliable Chest Walls → Pulm Contusion more likely than rib Fx ==> More Mobile Mediastinum → more susceptible to develop tension ptx ==> More Likely to Hyperventilate → Swallowed Air → compromise Respiratory status ==> Can compensate for significant volume loss with tachycardia Traumatic Asphyxia ==> Primarily in younger children ==> Due to the more pliable chest wall ==> Sudden, severe crushing blow to the chest when the glottis is closed. ==> Petechial Hemorrhages of sclera and skin of the head and upper extremities ==> Neuro deficits and coma due to cerebral edema can occur, although rare Pulmonary Contusion ==> Most Common thoracic Injury in kids ==> Alveolar Hemorrhage, Consolidation, Edema ==> Leads to: (1) V/Q mismatch (2) Decreased Compliance (3) Hypoxemia (4) hypoventilation

Category: Pediatrics

Title: Neonatal Resuscitation

Keywords: Neonatal Resuscitation, Newborn, Transilluminate, Meconoium Aspiration, Zip Lock Bag (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Neonatal Resuscitation 3 Key Questions to ask of your pregnant patients: ==> Are you having twins (or more)? ==> When is your due date? ==> What color is the fluid? Magic numbers for Neonatal Resuscitation: ==> HR < 100 (or persistent central cyanosis or apnea) = positive pressure ventilation ==> HR < 60 = chest compressions +/- epinephrine If there is meconium present and ==> The infant is depressed, then use meconium aspirator (aspirate the airway via the ETT) ==> The infant is vigorous, then resuscitate as usual (dry, clear airway, assess circulation/color) When resuscitating an infant who is <28wks GA, do not dry with towels as you would an older neonate, instead ==> Place the child in a food grade polyethylene bag (Zip Lock bag), to prevent heat loss and avoid losing valuable time during the resuscitation. For infants not responding to resuscitation, TRANSILLUMINATE the chest to determine if there is a pneumothorax.

Category: Pediatrics

Title: Intussusception

Keywords: Intussusception, Abdominal Pain, bloody stools, vomitting, change in mental status (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Intussusception Age: 3months to 6 years, most common among 3-12 months The classic triad: colicky abdominal pain, vomiting, and red currant jelly stools ==> Occurs in only 21% of cases. ==> Currant jelly stools are observed in only 50% of cases. ==> 75% without obviously bloody stools will have positive occult blood. A child vomiting without diarrhea should raise suspicion. Consider it in infant/toddler with change in mental status/lethargy (TIPS AEIOU one of the I s is for Intussusception). Choice of Radiographic Evaluation is often based upon your institutional resources ==> U/S is the modality of choice for imaging, but cannot treat. ==> Air contrast enema (now preferred over saline contrast) is useful for diagnosis and treatment. ==> Both are operator dependent

Category: Pediatrics

Title: ALTE

Keywords: ALTE , Apparent Life Threatening Events, color change, apnea, SIDS, Seizure (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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ALTE (Apparent Life Threatening Events) Defined as an episode characterized by some combination of apnea, color change, change in tone, choking, and/or gaging. Vast DDx ==> Get Bedside Glucose Early (should be part of vital signs) ==> Keep Non-accidental Trauma on the list ==> ~50% are classified as Idiopathic Risk Factors associated with Increased Mortality: ==> Sleep Onset ==> Prior Similar Episode ==> Sibling a Victim of SIDS ==> Development of Seizure D/O during monitoring 7.8% of ALTE pt s with a Normal ED evaluation required medical intervention during hospitalization. -Oren, J., D. Kelly, and D.C. Shannon, Identification of a high-risk group for sudden infant death syndrome among infants who were resuscitated for sleep apnea. Pediatrics, 1986. 77(4): p. 495-9. -De Piero, A.D., S.J. Teach, and J.M. Chamberlain, ED evaluation of infants after an apparent life-threatening event. Am J Emerg Med, 2004. 22(2): p. 83-6.

Category: Pediatrics

Title: SCIWORA

Keywords: SCIWORA, Spinal Cord Injury Without Radiographic Abnormality, MRI, steroids (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) Children <8yrs old can have their spinal cord stretched up to 5cm before rupture. Their cervical spinal columns are more mobile and held together with less stable ligaments allowing for horizontal movement of the vertebrae. The mobility of the spinal column allows for spontaneous reduction of subluxated vertebrae; therefore, CTs and plain radiographs will often appear normal at the time of ED evaluation. Any child with neurologic deficits or a concerning mechanism of injury deserves an MRI to evaluated for SCIWORA. No studies of the utility of steroids in children with spinal cord injury exist; current recommendations are to reserve methylprednisolone for those children who present with persistent or progressive neurologic deficits.

Category: Pediatrics

Title: NewBorn Resuscitation

Keywords: NewBorn Resuscitation, Neonate, Transilluminate, Bradycardia (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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NewBorn Resuscitation Important numbers to remember: ==> HR <100, start Positive Pressure Ventilation ==> HR <60, start Chest Compressions Bradycardia and Hypotonia are symptoms of Poor Ventilation and Acidosis With an infant who is not responding to resuscitation measures, TRANSILLUMINATE the chest to help detect a pneumothorax.

Category: Pediatrics

Title: Kawasaki s Disease

Keywords: Kawasaki s, Coronary Artery Aneurysm, fever (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Kawasaki s In the US, Kawasaki Disease is the leading cause of Acquired Heart Disease in Children (surpassing Acute Rheumatic Fever). ==> 15-25% of untreated pts develop coronary artery aneurysm or ectasia. Diagnosis is a clinical one. ==> 5 days of fever PLUS 4/5 clinical features (rash, inflammation of lips/mouth, bilateral conjunctivitis, edema or erythema of hands/feet, and peeling of fingers/toes). No lab values are diagnostic; however, they can strengthen clinical suspicion. ==> CRP and ESR are usually elevated. Thrombocytosis is also common after 1 week of illness. Symptoms are often transient and require careful history. Considered it in the DDx of every child with fever of at least several days duration, rash, and nonpurulent conjunctivitis, especially in children <1 year old and in adolescents, who often have incomplete Kawasaki Disease and are likely to be missed. Newburger, JW. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease. Circulation. 2004;110:2747-2771.