Emergency 3 Step 3

Any acute change in mental status of unclear etiology: naloxone, dextrose, and thiamine Gastric emptying: only be used if it is very clear that the overdose occurred during the last hour.CCS case, give naloxone, thiamine, and dextrose and give oxygen and saline while checking the toxicology screen-all at the same time. Gastric emptying: almost always wrong. useful on first hour after overdose, 1st hour: 50 percent of pills can be removed, 1-2 hours: 15 percent, 2 hours: useless. Never do it with caustics Ipecac never used in altered mental status and always wrong in children. Intubation and lavage: rarely performed with ingestion of substance within 1-2 hours and no response to naloxone, dextrose, and thiamine. If you have a toxicology case and do not know what to do give charcoal. can help in most overdose cases. will not harm anyone CCS Tip: ln overdose cases, do multiple things simultaneously: DCL from an overdose, give naloxone, thiamine, and dextrose at the same time as checking a toxicology screen, giving oxygen, and checking routine labs. overdose case "menu":, Specific antidote if the etiology is clear, Toxicology screen, Charcoal,CBC, chemistry, urinalysis, Psychiatry consultation if the overdose is the result of a suicide attempt, Oxygen for carbon monoxide poisoning or any dyspneic patient Antidotes: (Acetaminophen, N-acetyl cysteine), (Aspirin, Bicarbonate to alkalinize the urine), (Benzodiazepines, flumazenil), (Carbon monoxide, 100 percent oxygen, hyperbaric in some cases), (Digoxin, Digoxin-binding antibodies), (Ethylene glycol/Methanol --> Fomepizole or ethanol), (Methemoglobinemia, Methylene blue), (Neuroleptic malignant syndrome Bromocriptine, dantrolene), (Opiates, Naloxone), (Organophosphates, Atropine, pralidoxime), (Tricyclic antidepressants Bicarbonate protects the heart) CCS Tip: Alkalinize the urine with D5W with 3 amps of bicarbonate. Alkalinization of the urine facilitates excretion of the following: Salicylates (ASA), Tricyclic antidepressants (Ihis will show up on the urine tox you ordered.), Phenobarbital, Chlorpropamide On CCS, remember to order an aspirin, acetaminophen, and alcohol (ETOH) level on all overdose patients. There is a very high frequency of co-ingestion. Acetaminophen: 10 g is toxic, 15 g is fatal, lower if there is underlying liver disease or alcohol abuse. First 24 hours -> Nausea and vomiting, which resolve. 48-72 hours later: Hepatic failure. Give N-acetyl cysteine (NAC) to any patient with a possible overdose of a toxic amount. Useful to prevent liver toxicity up to 24 hours after the ingestion. After 24 hours, there is ro specific therapy to prevent or reverse the liver toxicity of acetaminophen. Vomiting patients can get NAC through the IV route. If the amount, equivocal, then get an acetaminophen leve, but do not wait to give NAC Aspirin: patient with tinnitus., hyperventilating, maybe ARDS, high gap Metabolic acidosis d.t loss of Krebs cycl, lactic acidosis from hypoxic metabolism Respiratory alkalosis: precedes the metabolic acidosis. Renal insufficiency, Elevated prothrombin time, Confusion, Severe cases show seizures and coma, Fever. On CCS, order: CBC, Chemistry panel, ABG, ,PT/INR/PTT, Salicylate (ASA) level.

Treatment: Alkalinize the urine, charcoal to block absorption, Dialysis is used in severe cases. Benzodiazepine overdose (by itself) is not fatal. Let the patient sleep! Move the clock forward on CCS, and the overdose will pass. Don't give flumazenil as you do not know who has chronic dependency so it can induce benzodiazepine withdrawal and seizures. Opiate toxicity: death from respiratory depression. One cannot die from opiate withdrawal., Treat acute overdoses with naloxone. Digoxin overdose: MC presentation is GI disturbance, also yellow "halos" around objects and blurred vision. Any arrhythmia is possible. You may see PR prolongation; there may also be "paroxysmal atrial tachycardia with block, Encephalopathy. Hypokalemia may lead to digoxin toxicity and toxicity leads to hyperkalemia from poisoning of the sodium/potassium ATPase. Rx: digoxin-binding antibodies (Digibind) for, central nervous system and cardiac abnormalities. TCA overdose: Death, due to seizures or arrhythmia. Most urgent step: EKG for wide QRS (most likely to develop VT or torsade de pointes), any patient with wide QRS or arrhythmia, give bicarbonate and transfer to lCU. Anticholinergic effects: Dilated pupils, Dry mouth, Constipation, Urinary retention. Organophosphates: inhibit acetylcholinesterase, Crop duster exposed to insecticides or nerve-gas attack, Make sure not to spread the contaminate. When caring for victims of be protected as the toxin is absorbed through skin. Symptoms: Salivation, Lacrimation, Urination, Diarrhea, Wheezing from bronchospasm, Bronchorrhea. Rx: BI is Atropine, Most effective is Pralidoxime, Remove the clothes and wash the patient. Ethytene Glycol and Methanol: both present with high gap metabolic acidosis. Ethylene glycol causes renal insufficiency from direct toxicity, Hypocalcemia from precipitation of the oxalic acid with the calcium, Kidney stones. Methanol presents with: Visual disturbance, Retinal hyperemia due to formic acid. Rx: Ethanol or fomepizole, Dialysis to avoid toxic metabolites. Methemoglobinemia: hemoglobin locked in an oxidized state. Cyanosis with normal PO2, Shortness of breath, Dizziness, Headache, Confusion, Seizures. History: nitrates or nitroglycerin, anesthetics, dapsone, or other oxidants. drugs ending in -caine. (e.g., lidocaine, benzocaine, bupivicane) as little as the anesthetic spray put into the throat of a patient who will be intubated Dx: Normal pO, on ABG with chocolate-brownish blood (oxidized blood), Methemoglobin level. Rx: 100% oxygen, Methylene blue restores the hemoglobin to normal state. Most common cause of death in fires is carbon monoxide (CO) poisoning, presents with Shortness of breath, Lightheadedness and headaches, Disorientation, Severe disease causes metabolic acidosis from tissue hypoxia. Commonly presents in families that are "snowed in" and can't leave their house with a woodburning stove, Everyone is fatigued and has a headache. Look for the phrase "He feels better when he is shoveling snow. If CO poisoning is suspected, call an ambulance. Give 100 percent oxygen to all survivors from a fire until you have their CO levels. Burns: most important is 100% O2 as mcc of death in fires is CO poisoning, then determine who

needs ETT (Hoarseness, Wheezing, Stridor, Burns inside the nose or the mouth) then give fluids as 4 mL of lactated Ringers or normal saline /percentage of 2nd or 3rd degree burn/Kg. All heat disorders present with rhabdomyolysis, possibly confusion or seizures, life-threatening rhythm disturbance can occur from the hyperkalemia. Neuroleptic Matignant Syndrome (NMS): ingestion of neuroleptic meds as phenothiazines. no specific diagnostic test, CPK and potassium levels can be elevated. Muscle rigidity is common., Treat, dopamine agonists cabergoline or bromocriptine. Dantrolene is also effective. Malignant Hyperthermia: anesthetic use. no clinical distinction between NMS and malignant hyperthermia, just different risks of medications. Treat with dantrolene. Heat Stroke: exertion when the outside temperature is high and you are dehydrated or exerting yourself. can get same symptoms as NMS and malignant hyperthermia. Rx: physical removal of heat body (spraying the patient with water, fanning the patient in an airconditioned room, using ice baths/packs). Do not infuse iced saline as it0 can stop the heart. Heat stroke: Dry skin, Altered mental status, high temperature, Elevated, Rx: Spraying patient with water and applying ice baths/packs Heat exhaustion: excessive sweating, N&V, high temp, Rx: Normal saline lV (room temp) and removal patient to cool environment Hypothermia: alcoholic falling asleep outside in winter., kills with rhythm disturbance. most urgent step is EKG: "f-waves of Osborn," looks like ST segment elevation is most specific finding. Bite of a black widow spider: abdominal pain, rigidity, and hypocalcemia. Mimics organ perforation but there is pain without tenderness. Rx: antivenin. Brown Recluse Spider: local necrosis, bullae, and dark lesions. Rx: wound debridement, steroids and dapsone may help. Retinal Detachment: sudden loss of vision like "a curtain coming down." Consult ophthalmology, perform a dilated retinal examination. Rx: Tilt the head back, Reattach the retina (surgery, cryotherapy, injecting an expansile gas into eye). If these fail, place a band around the eye to get the retina close to the sclera. Red eye: Acute angle closure glaucoma: ophthalmologic emergency, red eye with fixed midpoint pupil, Rock-hard, painful eye. Dx: tonometry. Rx: BI: pilocarpine drops (constricts the pupil), Mannitol (osmotic diuretic) to help open the angle. Other therapies: Acetazolamide (Decreases production of aque6us humor), PG analogs (Latanoprost, travoprost), topical BB (Timolol), Alpha agonists (Apraclonidine) Red eye: Coniunctivitis: Viral: Bilateral watery discharge, itchy eyes. Bacterial: Unilateral purulent discharge, eyelids stuck together. Rx: topical antibiotics for bacterial form. Red eye: Uveitis: Photophobia. Dx: Slit lamp examination. Rx: Steroids Red eye: Abrasion: History of trauma, most commonly from contact lenses. Dx: Fluorescein stain. No specific therapy. Do not patch abrasions caused by contact lenses.