Welcome Applicants! FRIDAY, OCTOBER 24

Transcription

1 Welcome Applicants! FRIDAY, OCTOBER 24

2 Friday Prep A 3-year-old girl is brought to your office for re-evaluation of a fever that began 6 days ago. Her mother tells you that her daughter s temperature has been as high as 102.2F. Her physical examination was unremarkable when you examined her 3 days ago, but today you note injected sclera; cracked, red lips; a strawberry appearance of her tongue; and a swollen, nontender, cervical node. You tell her mother that you believe this is Kawasaki disease. Of the following, the MOST important statement to make to the mother is that: A. An exercise stress test should be performed as a baseline study. B. Aspirin therapy will be used until the fever subsides. C. Cardiac involvement may include abnormalities of the coronary arteries or the myocardium. D. Echocardiography should be performed if patient has EKG changes. E. Immediate treatment with intravenous immune globulin will eliminate the chance of coronary involvement.

3 16 yo female with altered mental status

4 16 yo female with altered mental status

5 Ingestions and Toxidromes * = CONTENT SPEC

6 With any ingestion Medications may look like candy to toddlers!! Older kids & adolescents- usually intentional Remember your ABCs! Treat the patient, not the poison History & Physical There may be no specific history of ingestion Are there any pills left? Vital signs, pupil size, skin, neurologic status

7 Our patient s ingestion- Valproic Acid (Depakote) Based on clinical history Death may occur with acute toxicity Temperature fluctuations, tachycardia, hypotension, resp depression Coma, confusion, ataxia, cerebral edema Anorexia, NV Tremors and chorea Miosis and nystagmus Supportive care with activated charcoal, hemodialysis, L-carnitine Consider other co-ingestions

8 Pick your poison Caustic liquids Acetaminophen Antihistamines PCP Cocaine Beta Blockers Methanol Ethanol Organophosphates Salicylate Hydrocarbons Amphetamine TCAs Ethylene Glycol Opioid Ibuprofen

9 Beta-blockers Primary effect Loss of beta receptor specificity in large doses Doses of just 2-3x therapeutic dosing can be fatal How do patients present?* Depressed sensorium (or even seizures!) Bradycardia, hypotension, diaphoresis* Hypoglycemia, Hyperkalemia Diagnosis/Management Fluids/Pressors Glucagon, Magnesium Bronchodilators Admit ANY pediatric ingestion, ECG monitoring for at least first 6 hours

10 Pick your poison Caustic liquids Acetaminophen Antihistamines PCP Cocaine Beta Blockers Methanol Ethanol Organophosphates Salicylate Hydrocarbons Amphetamine TCAs Ethylene Glycol Opioid Ibuprofen

11 Caustic Agents (detergent, bleach)* Primary effect Direct contact; not likely to see systemic sxs on presentation Alkali- liquefactive necrosis (esophagus +/- perforation) Acidic- coagulation necrosis of esophagus + stomach (already acidic stomach)* How do patients present? May present without OP lesions Drooling, dysphagia, emesis Coughing +/- wheeze or stridor, crying, CP Edema/obstr. may be delayed up to 48 hrs Diagnosis/Management Admit! H2 blockers Endoscopy within hours*

12 Pick your poison Caustic liquids Acetaminophen Antihistamines PCP Cocaine Beta Blockers Methanol Ethanol Organophosphates Salicylate Hydrocarbons Amphetamine TCAs Ethylene Glycol Opioid Ibuprofen

13 TCA (tx of enuresis, depression)* Primary effect Anticholinergic overload (no acetylcholine) How do patients present?** Mydriasis, dry mouth, tachycardia, HTN, urinary retention, constipation Dysrhythmias- first 24 hrs to 2-5 days later* Management* Charcoal Dysrhythmias do not lead to V fib do not need to treat with cardiac meds NaBicarb boluses for widened QRS, repeat until QRS < 100ms Benzos for seizures Must observe for at least 6 hours

14 More on TCAs and other anticholinergics TCAs render allergy testing unreliable- they intervene with histamine response Other anticholinergic agents to think about: Antispasmodics Jimson weed Phenothiazines Atropine Antihistamine Physostigmine can be use to treat anticholinergic effects from antihistamine toxicity (cannot use in TCA OD)

15 Pick your poison Caustic liquids Acetaminophen Antihistamines PCP Cocaine Beta Blockers Methanol Ethanol Organophosphates Salicylate Hydrocarbons Amphetamine TCAs Ethylene Glycol Opioid Ibuprofen

16 Hydrocarbons (gasoline, lamp oil, solvents, rubber cement) Primary effect Destroys surfactant with alveolar collapse, VQ mismatch, hypoxemia Only takes 1cc of fluid! How do patients present? Nonspecific: N/V Choking/gagging with persistent cough, tachypnea, grunting, cyanosis Pneumonitis may be delayed up to 24 hours ARDs Diagnosis/Management* Asymptomatic- 6 hours observation further management depends on CXR Symptomatic- Admit for supportive care!

17 Pick your poison Caustic liquids Acetaminophen Antihistamines PCP Cocaine Beta Blockers Methanol Ethanol Organophosphates Salicylate Hydrocarbons Amphetamine TCAs Ethylene Glycol Opioid Ibuprofen

18 Organophosphates (lawn care, pesticides) Primary effect Inhibition of acetylcholinesterase (acetylcholine overload) Routes: PO, inhalation, skin absorption How do patients present? Muscarinic: SLUDGE (salivation, lacrimation, urination, diarrhea, emesis), miosis, bradycardia, hypotension, sweating Nicotinic- fasciculations, paralysis Other: AMS, HA, tremor, seizures Diagnosis/Management* Gastric Lavage if recent, activated charcoal Pralidoxime- reactivates acetylcholinesterase Atropine- temporary blockade of excess acetylcholine

19 Pick your poison Caustic liquids Acetaminophen Antihistamines PCP Cocaine Beta Blockers Methanol Ethanol Organophosphates Salicylate Hydrocarbons Amphetamine TCAs Ethylene Glycol Opioid Ibuprofen

20 Opioids (Codeine, Morphine) Classic triad: miosis, coma, respiratory depression* System CNS Respiratory Cardiovascular Gastrointestinal Musculoskeletal Dermatologic Urinary Endocrine Symptoms Seizures, reflex suppression Aspiration, noncard. Pulmonary edema Bradycardia, orthostatic hypotension NV, constipation Relaxed tone to rigidity Pruritus, flushing Decreased formation, retention Increased ADH secretion Diagnosis/Treatment Naloxone + Supportive care*

21 Pick your poison Caustic liquids Acetaminophen Antihistamines PCP Cocaine Beta Blockers Methanol Ethanol Organophosphates Salicylate Hydrocarbons Amphetamine TCAs Ethylene Glycol Opioid Ibuprofen

22 Acetaminophen The most common culprit in ODs Toxicity: liver damage via metabolite NAPQI, which is normally conjugated with glutathione. Glutathione is depleted in overdoses Minimum dose 140mg/kg; severe toxicity >250mg/kg Initially: anorexia, NV (about 24 hours)* 1-3 days after ingestions- RUQ pain, increase in liver enzymes* 3-5 days- resolution OR progression to hepatic failure & encephalopathy* Remember: LFTs can be normal for 2-3 days

23 Acetaminophen A 4 hour acetaminophen level is the most important predictor of patient outcome! Management:* Charcoal N-acetylcysteine (start within 10 hours) If known ingestion of >150mg/kg- give NAC before drawing labs

24 Pick your poison Caustic liquids Acetaminophen Antihistamines PCP Cocaine Beta Blockers Methanol Ethanol Organophosphates Salicylate Hydrocarbons Amphetamine TCAs Ethylene Glycol Opioid Ibuprofen

25 Salicylates (cold meds, bismuth subsalicylate, oil of winter green) MoA: uncouples oxidative phosphorylation, inhibits Kreb s Initial complaints: Nausea and vomiting (GI irritation), tinnitus, fever, agitation Physical exam:* Tachypnea, tachycardia Pulmonary edema from increased vascular permeability

26 Salicylates Peaks at 4-6 hours LABS Anion gap metabolic acidosis* AND respiratory alkalosis Hypokalemia Level 3-6 hours post ingestion (follow q2-3 hr until <30mg/dl) Management* Activated charcoal NaBicarb (to enhance elimination) Gastric lavage if within 1 hour Correct dehydration and electrolytes Dialysis if level >100mg/dl

27 Pick your poison Caustic liquids Acetaminophen Antihistamines PCP Cocaine Beta Blockers Methanol Ethanol Organophosphates Salicylate Hydrocarbons Amphetamine TCAs Ethylene Glycol Opioid Ibuprofen

28 Ethanol Dose-related depressant Mild: lowered inhibitions, impaired coordination, nystagmus Mod: slurred speech, ataxia, impaired judgment, mood swings Severe: confusion and stupor Hypothermia, bradycardia Significant hypoglycemia in children* Due to inhibition of gluconeogenesis Ethanol may mask the toxicity of other drugs* Screen for other ingestions! Labs: ethanol level, electrolytes, glucose Treatment: supportive

29 Others to think about: Ethylene glycol Sweet-tasting, odorless, colorless Drunken appearance but no odor of alcohol on breath, large anion gap, oxalate crystals on UA PCP: Wide-eyes, violent, asymmetric pupils Amphetamine: Mental status changes and tachycardia; absence of dry, flushed skin; anhidrosis; urinary retention

30 What s the magic number for poison control?

31 THE END HAVE A GREAT DAY! Noon Conference: Dr Williams, Refractory ADHD