Trauma

Posted on 1 August، 2019 Tagged ER, SurgeryLeave a comment

1˚ ABC

Airway	Airway is safe if pt can: conscious and speaking in a normal tone of voice. AW is endangered if: if expanding hematoma or emphysema in the neck. Intubate when: · GCS 8 or low · Breathing is gurgling / abnormal · Inhalation injury If there is cervical spinal injury, handle AW 1˚, it’s more important. · USE ENDOTRACHEAL INRUBATION (FROM MOUTH TO TRACHEA) · If laryngospasm, severe maxillofacial injuries, an impacted foreign body that cannot be dislodged –> Cricothyroidomy. · Use a fiberoptic bronchoscope if subcutaneous emphysema in the neck → MUST: it is a sign of major traumatic disruption of the tracheobronchial tree.
Breathing	Hearing breath sounds on both sides of the chest and having satisfactory pulse oximetry establishes that breathing is okay.
Circulation	· Insert large bore IV · Check if pt is in shock or not. · Manage Shock
Disability	· GCS · Pupil · Neurological Sx
Exposure	Expose the pt

Rx from head to toe:

Head

Any loss of consciousness	CT
Concussion	Contusion
No focal finding	Rarely focal
No lucid interval	No lucid interval
Normal CT	Ecchymoses
No specific treatment; observe at home for lucid interval or new focal findings	No specific treatment; observe in hospital
Subdural hematoma	Epidural hematoma
+/– focal findings	+/– focal findings
+/– lucid interval	+/– lucid interval
Venous, crescent	Arterial, biconvex or lens-shaped hematoma
Drain large ones	Drain large ones
LARGE ONES ARE?	· Compression of ventricles or sulci · Herniation with abnormal breathing and unilateral dilation of the pupil · Worsening mental status or focal findings
If midline structures are deviated	craniotomy will help, but prognosis is bad.
If there is no deviation	therapy is centered on preventing further damage from subsequent increased ICP. 1. Elevate head 2. Hyperventilate (<pco2 35) a. Hyperventilation is recommended when there are signs of herniation, and the goal is a PCO 2 of 35. 3. Mannitol
How to ⤵️ O2 demand?	Sedation and hypothermia have been used to decrease brain activity and oxygen demand. Hypothermia is currently suggested as a better option to reduce oxygen demand.

Evaluation of head trauma in children age 2-18 👧:

Clinical scenario	Recommendation
Any of the following: · Focal neurologic findings · Skull fracture, especially signs of basilar skull fracture · Seizure · Persistent altered mental status (e.g., agitation, lethargy, slow response) · Prolonged loss of consciousness	Head CT without contrast
GCS = 15 with any of the following: · Vomiting · Headache · Questionable or brief loss of consciousness · Injury caused by high-risk mechanism of injury · Severe mechanism of injury	Clinical preference: Observation for 4-6 hours OR Head CT without contrast
Minor head trauma (GCS = 15 with non-severe mechanism and no vomiting, headache, loss of consciousness, or signs of fracture)	No head CT

NECK TRAUMA

Penetrating trauma	expanding hematoma / Unstable VS / or clear signs of esophageal or tracheal injury (coughing or spitting up blood) → Surgical exploration.
Gun shot:	· if upper areas –> arteriographic diagnosis and management · If base of neck –> arteriographic + enema (visualize esophagus) for diagnosis and management
Stab wounds to the upper and middle zones	Asx pts can be safely observed.
PT w/ Severe blunt trauma to the neck,	the integrity of the cervical spine has to be ascertained.
If there are neurologic deficits / or pain on palpation of cervical spine	Order CT.

Spine Trauma

General management	Prehospital: · Spinal immobilization (e.g., backboard, rigid cervical collar, lateral head support) · Careful helmet removal (e.g., motorcycle helmet) · Airway oxygenation Emergency department: · Orotracheal intubation preferred UNLESS significant facial trauma present · Rapid-sequence intubation added for unconscious patients who are breathing but need ventilatory support · In-line cervical stabilization suggested UNLESS it interferes with intubation · CT of entire cervical spine · Monitoring for neurogenic shock from spinal cord injury
1˚ No pelvic / urethral injury	Bladder Cath
2˚ Imaging	MRI is preferred over CT.
Compression / Neurological sx	IV STEROIDS –> CT
Complete cut of SC	Nothing below lesion (no sensory nor motor)
Brown sequard (hemisection)	· You lose 3 tracts · STT: contralateral loss · note: loss starts 2 levels below · DC: ipsilateral loss · CS: ipsilateral loss
Anterior cord	You lose motor + STT. Burst injury. So: · Motor below injury is gone · STT: contralateral loss
Central cord	· elderly with forced hyperextension of the neck · paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities.

CHEST

Rib Fx

· Rib fracture can be deadly in the elderly,

· because of progression of pain → hypoventilation → atelectasis → pneumonia.

· Tx: pain control.

	Features	Dx	Tx
Aortic injury	· Blunt trauma · Anxious pt · HTN / PAIN · CXR: · Mediastinal deviation · Mediastinal widening	CT	Anti-HTN Surgery
Diaphragmatic Rupture	Presents w/ either: · Resp distress · S/S of SBO · Abd pain referred to shoulder	CXR: bowel in chest	Surgery
Esophageal Rupture	· Mediastinal widening · Chest pain · crepitus & ⊕ Hamman sign · Pleural effusion: green	Esophagogram: air leak from esophagus	· NPO · IVF · ABx · Surgery 🚨
Bronchial Rupture	· PTX that doesn’t resolve w/ chest tube · Pneumomediastinum · Subcutaneous emphysema	CXR	Surgery
Myocardial Rupture	Death	–	–
Myocardial Contusion	Can presents as it pleases: · As MI · Arrhythmia · Wall injury · Temponade · HF · Most common association: sternal fx	Urgent Echo +ECG changes Troponin high	· Tx based on Sx · If CHF: diuretics
PTX	Clear	Clear	Chest tube

PTX	Hemothorax
· here not tension pneumothorax, · same finidings · Dx: clx –> CXR · Tx: tube	· same pathophysiology, but w/ blood, and it goes down, not up. · Dullness on percussion · Dx: CXR · Tx: · Chest tube · YOU MUST DDx b/w lung bleeding vs. Vessel bleeding. · Lung bleeding stops on its own, · Vessels do not · How to ddx? · amount of blood, if >1500, go to OR. (thoracostomy)
Sucking Chest wound	Flail chest
جرح يدخل الهواء جوا بس مايطلعه برى. lead to tension pneumothorax Tx: cclusive dressing that allows air out (taped on 3 sides) but not in	كذا عظم صدر انكسر، ويصير يتحرك عكس اتجاه التنفّس، إذا سوى شهيق (تدخل)، وإذا زفير (تطلع) issue is risk of pulmonary contusion. Tx: Binders

Flail chest:

Pathophysiology	≥3 contiguous ribs fractured in ≥2 locations → flail chest segment
Findings	· Paradoxical chest wall motion with respiration · Chest pain, tachypnea, rapid shallow breaths · CXR: rib fractures +/- contusion/hemothorax
Management	· Pain control, supplemental oxygen · PPV (+/- chest tube) IF respiratory failure

Pulmonary contusion:

Clinical features	· Present <24 hours after blunt thoracic trauma · Tachypnea, tachycardia, hypoxia
Diagnosis	· Rales or decreased breath sounds · CT scan (most sensitive) or CXR with patchy, alveolar infiltrate NOT restricted by anatomical borders
Management	· Pain control · Pulmonary hygiene (e.g., nebulizer treatment, chest PT) · Supplemental oxygen and ventilatory support

· can appear up to 48 hours later

· Dx: CXR (whitining of lungs)

· Tx:

· do not add fluid!

· Diuretics.

Esophageal perforation:

?	· Instrumentation (endoscopy) · Trauma · Boerhaave syndrome/ Esophagitis
Clx	· Chest, back and/or epigastric pain · Systematic signs such as fever · Crepitus, Hamman sign (crunching sound auscultation) · Pleural effusion with atypical (e.g. green) fluid
Dx	· CXR/CT: widened mediastinum, pneumomediastinum, PTX · CT: esophageal wall thickening, mediastinal fluid collection · Esophagography with water soluble contrast: leak from perforation
Tx	· NPO, IV Abx and PPI · Emergency surgical consultation 🚨

Aortic dissection

· ينشخل الأورطة

· w/ deceleration injury

· CT Angio

· Surgery or pt die.

Abdomen

§ In patients who have blunt abdominal trauma, resuscitation must coincide with physical examination and diagnostic testing aimed at determining the presence or absence of hemoperitoneum and organ injury. Abdominal wall ecchymosis, abdominal distention, and decreased abdominal sounds may be clues to intra-abdominal injury.

§ FAST US provides an easy and rapid way to assess intra- abdominal injuries and presence of peritoneal fluid. Unstable patients should undergo a FAST examination as part of the initial assessment. Evidence of free fluid on the FAST examination is an indication to avoid diagnostic imaging and go immediately to the ORto correct the source of bleeding. CT scan is the test of choice for patients who have blunt abdominal trauma who meet criterion for evaluation (stable).

§ Most abdominal gunshot wounds require immediate exploratory laparotomy.

§ CT scan is done in cases of blunt trauma to diagnose intra-abdominal bleeding and to identify intra-abdominal injuries if the patient is stable enough to go to the CT scanner.

§ If there is concern for internal bleeding in an unstable patient (hypotension and/or tachycardia), investigate further with an FAST scan or diagnostic peritoneal lavage.

Abdominal trauma:

GENERAL RULES:

If the patient is

1- Peritoneal → OR (exploratory laparotomy)

2- GIT is out → OR (exploratory laparotomy)

3- hemodynamically unstable-FAST⊖→ high susceptibility of internal bleeding → OR(exploratory laparotomy)

Gun shot → OR

Stab wound → follow the rule –⊖→digital exam of the area

Blunt → follow the rule –check for hidden bleeding –FAST

i. ⊕ → OR

ii.⊖→ CT?

→ OR?

→ watch and wait (w/w)

Complications of OR

1- coagulopathy – PLT + FFP

2- coagulopathy + hypothermia + lactic acidosis → STOP OR 🛑

3- prolonged laparotomy – Day 2 post-op –risk of compartment syndrome

Management of blunt abdominal trauma in hemodynamically unstable patients:

Focused assessment with sonography for trauma – FAST- examination

IF THE EXAMINATION

1- positive → laparotomy

2- inconclusive → DPL

IF ⊕ → laparotomy

IF ⊖→ signs of extra-abdominal hemorrhage (e.g. pelvic/ long bone fracture)?

YES? → stabilize (e.g. angiography, splint)

NO? → stabilize, then CT of the abdomen

3- negative → signs of extra-abdominal hemorrhage (e.g. pelvic/ long bone fracture)?

YES? → stabilize (e.g. angiography, splint)

NO? → stabilize, then CT of the abdomen

Pelvis

· Pelvic hematomas are typically left alone if they are not expanding.

· Check for other injuries (rectum, bladder, vagina, urethra “men”)

UROGENITAL

Bloody meatus

Retrograde

Compartment syndrome:

(early pain + paresthesia → S/M Sx)

Common:

· Pain out of proportion to injury

· Pain ⤴️ on passive stretch

· Rapidly increasing and tense swelling

· Paresthesia (early)

Uncommon:

· ⤵️ sensation

· Motor weakness (hours)

· Paralysis (late)

· ⤵️ distal pulses (uncommon)

Vascular

Extremity vascular trauma:

Clx	Hard signs · Observed bleeding · Presence of bruit/thrill over injury · Expanding hematoma · Signs of distal ischemia Soft signs Δ · Diminished pulses · Bony injury · Neurologic 🆎
Tx	If (hard) signs or HD unstable · Surgical exploration Otherwise · CT scan or conventional angiography · Duplex Doppler ultrasonography

BURN

Burns

Features

· Burn.

· Associated stuff: CO / Cyanide poisoning

S/S

· Erythema/Superficial	· 1st degree	· Epidermis	· + Pain · Blanchable
· Superficial-partial thickness	· 2nd degree	· Into superficial dermis	· + Pain · Blanchable · Blisters
· Deep-partial thickness	· 3rd degree	· Into deep dermis	· – Pain · NOT blanchable · Soft
· Full thickness	· 4th degree	· Into underlying muscle/bone	· – Pain · NOT blanchable · Hard

· Clx

· ABC

· Remove all clothing

· if inhalational injury is suspected, best next step: immediate intubation

· Best dx test → Bronchoscopy

· if chemical burn, best next step: irrigation

· if burn eschar encircles chest, best next step: escharotomy to relieve constriction

· Fluid:

· 4*kg*BSA

· Lenger lactate

· 1st 8 h: 1st half

· Tetanous ppx: all patients with > 10% BSA burn or burn worse than superficial thickness need Td

· Stress ulcer ppx: Antaacid

Comp

· Severe burns are often complicated by wound infections and sepsis.

· They also can present later (years later) w/ SqCC of skin.

Substance Abuse

Posted on 30 July، 2019 Tagged ERLeave a comment

Drug	intoxication	Withdrawal (opposite of intoxication)
Alcohol	Drunk · Inappropriate sexual behavior · forgets what happened	D1: Tremor D2: Tactile hallucinations / SZ D3: Delirium Tremens + Unstable VS
Tx	If pt is hypoxic: mechanical ventilation	benzodiazepines Thiamine Folic Acid
benzodiazepines	~ Drunk · Inappropriate sexual behavior · forgets	Autonomic hyperactivity, tremors, insomnia, seizures, anxiety (~ alcohol)
Tx	Flumazenil	Benzo taper down ✳️
COcaine & Amphetamine	⊕ Sympathetic Euphoria, hypervigilance (مصحصح), autonomic hyperactivity, weight loss, papillary dilatation, perceptual disturbance 👶🏼: Prenatal exposure to cocaine can result in jitteriness, excessive sucking, and a hyperactive Moro reflex (due to the toxic effects of cocaine)	Feeling depressed/bad crash (sleeps a lot) increase appetite (parasympathetic comes back) anxiety Risk of suicide
Tx	· benzodiazepines · short-term use of antipsychotics, · vitamin C to promote excretion in urine, · anti-hypertensives	· Antidepressants
Opioids	⤵️ activity (أكثر من اللازم مهوّي) mu blocking: ⤵️ HR ⤵️ RR Pupil constriction GI sphincter constriction Apathy, dysphoria, drowsiness, slurred speech, impairment in memory, coma or death	body attacks back w/ ⤴️ activity mu overactivation: ⤴️ HR ⤴️ RR GI cramps / diarrhea yawning, lacrimation, runny nose fever, chills In 👶🏼: can lead to 3 things: · IUGR · Sudden death · Neonatal Abstinence syndrome: o high-pitched cry, o sleeping and feeding difficulties, o tremors, seizures, o autonomic dysfunction (sweating, sneezing), o tachypnea, o vomiting + diarrhea
Tx	Naloxone	Clonidine, methadone
Cannabis Marijuana	· Slow sense of time · Impaired motor coordination · conjunctival injection · dry mouth / tachycardia · ⤴️ appetite	ø
Tx	ø	ø
Bath salts	new stuff Amphetamine analogues Paranoia ⤴️ FEVER (41˚ ) ⤴️ ⤴️ ⤴️ BP (dangerous) Hallucinations VIOLENCE Can cause serotonin syndrome	ø
Tx	Supportive Benzo	ø
PCP	VIOLENT Need 20 cups to stop him nystagmus SZ	ø
Tx	benzo	ø
Ectasy	Synthetic amphetamine. MDMA Used in parties 🎉🎊 · ⤴️ Sociability · ⤴️ sexual desire · empathy Toxicity: · Amphetamine toxicity · SEROTONIN SYNDROME ✳️
Tx
Hallucinogens
Tx
Inhalants	rash around mouth fast action 15 m CNS Depressants
Tx	ø	ø

Alcohol withdrawal syndrome
Sx	S/S	⏰
Mild	– Anxiety, insomnia, – tremors, diaphoresis. palpitations, GI upset, intact orientation	Day 1
SZ	Single or multiple generalized tonlotIonic	Day 2
Hallucination	– Visual, auditory, or tactile; – intact orientation; – stable vital signs	Day 2
Delirium tremens	– Confusion. agitation, – fever, tachycardia, – hypertension, – diaphoresis. hallucinations	Day 3

Clues to Surreptitious Cocaine Abuse
Behavioral	Personality & mood changes. Changes in sleep patterns. Unexplained weight loss.
Sx	Chest pain. Epistaxis, rhinitis Headaches.
PEx	HTN, tachycardia. Dilated pupils. Psychomotor agitation
Complications	SZ – ICH Acute MI. Aortic dissection.

Clinical features of cocaine use
Clinical features	– Sympathetic hyperactivity – tachycardia, hypertension, dilated pupils – Chest pain due to coronary vasoconstriction – Psychomotor agitation, seizures
Complications	– Acute myocardial ischemia – Aortic dissection – Intracranial hemorrhage
Management of chest pain	– Benzodiazepines for blood pressure & anxiety – Aspirin – Nitroglycerin & calcium channel blockers for pain – Beta blockers contraindicated – Fibrinolytics not preferred due to increased risk of intracranial hemorrhage – Immediate cardiac catheterization with reperfusion when indicated

Clinical features of ACUTE opioid intoxication
RF	– Substance abuse – Chronic opioid use – Hospitalized pts (especially post-op) – Hepatic or renal insufficiency
Clx	– Somnolence, AMS – Pinpoint pupils (miosis) – Shallow breathing & 1 respiratory rate – Bradycardia, hypothermia, 1 bowel sounds – Respiratory acidosis on ABG
Tx	– Naloxone (may need repeated dosings) – Airway management & ventilation – Exclude other AMS causes (eg, hypoglycemia)

Opioids Withdrawal
Clx	– Acute opioid cessation/dose reduction after prolonged use. – GI: nausea, vomiting, diarrhea, cramping, I bowel sounds. – Cardiac:i pulse, i blood pressure, diaphoresis. – Psych: insomnia, yawning, sad mood. – Other: myalgias, arthralgias, lacrimation, rhinorrhea, piloerection, mydriasis.
Tx	– Opioid agonist: methadone (preferred) or buprenorphine. – Nonopioids: Clonidine or adjunctive medications (antiemetics, antidiarrheals, benzodiazepines).

Methamphetamine

Sx:

paranoid delusions,

tactile hallucinations (eg, bugs crawling under the skin), aggressive behavior,

severe insomnia,

physical findings of poor dentition,

bruxism (ie, teeth grinding),

skin sores

Heavy use frequently causes

weight loss, psychotic symptoms, and excoriations due to chronic skin picking. Severe dental problems (“meth mouth”). violent behavior,

signs of sympathetic overactivity (eg, elevated pulse and blood pressure, hyperthermia, sweating, pupillary dilation).

Some chronic methamphetamine users can develop persistent psychosis that may be difficult to distinguish from primary psychiatric disorders. Visual and tactile hallucinations tend to be more common in substance-induced psychotic disorders.

***

Tx: both CBT to prevent relapse and antipsychotic medication.

Clinical features of cocaine use
Clx	– Sympathetic hyperactivity – tachycardia, hypertension, dilated pupils – Chest pain due to coronary vasoconstriction – Psychomotor agitation, seizures
Comp	– Acute myocardial ischemia – Aortic dissection – Intracranial hemorrhage
Tx chest pain	– Benzodiazepines for blood pressure & anxiety – Aspirin – Nitroglycerin & calcium channel blockers for pain – Beta blockers contraindicated – Fibrinolytics not preferred due to increased risk of intracranial hemorrhage – Immediate cardiac catheterization with reperfusion when indicated.

Common withdrawal syndromes
Substance	Sx	PEx
Alcohol	Tremors, agitation, anxiety, delirium, psychosis	Seizures, tachycardia, palpitations.
Benzodiazepines	Tremors, anxiety, perceptual disturbances, psychosis, insomnia
Heroin	Nausea, vomiting, abdominal cramping, diarrhea, muscle aches	Dilated pupils, yawning, piloerection, lacrimation, hyperactive bowel sounds.
Stimulants (cocaine, amphetamines)	Increased appetite, hyper insomnia, intense psychomotor retardation, severe depression (“crash”)	No significant findings
Nicotine	Dysphoria, irritability, anxiety, increased appetite
Cannabis	Irritability, anxiety, depressed mood, insomnia, decreased appetite	No significant findings

Clinical features of acute opioid intoxication
S/S ↓ vitals	– ↓ Mental status. – ↓ RR (shallow breath/ ↓ HR – ↓ Miosis (normal/enlarged if co-ingestions) – ↓ Bowel sounds. – ↓ T’ ( or Ⓝ)
Dx	– ABG: Respiratory acidosis. – Fingerstick: ↓ Glu – Evaluation for presence of other drugs (eg, acetaminophen). – ECG: Prolonged QT.
Tx	– Naloxone, – Airway management & ventilation. – Consider continuous cardiac monitoring (if QTc >500 msec)

Ingestions & Poisoning

Posted on 30 July، 2019 Tagged ERLeave a comment

Anaphylaxis
?	– Food / drugs / Latex.
CIx	– Vasodilation à Hypotension & Tissue edema. – Upper AW edema à Stridor & Hoarseness. – Bronchospasm à Wheezing. – Urticria, Pruritus, Flushing. – N/V, Abdominal pain.
Tx	– IM Epinephrine (Rx if needed). – AW management & IVF. – Adjunctive (antihistamines, GCS).

Caustic ingestion
Clx	Chemical burn or liquefaction necrosis resulting in: – Laryngeal damage: Hoarseness, stridor. – Esophageal damage: Dysphagia, Odynophagia. – Gastric damage: Epigastric pain, bleeding.
Tx	– Secure airway, breathing, circulation. – Decontamination: Remove contaminated clothing & visible chemicals: irrigate exposed skin. – Chest X-ray if respiratory symptoms. – Endoscopy within 24 hours.
Comp	– Upper airway compromise. – Perforation. – Strictures/stenosis (2-3 weeks). – Ulcers. – Cancer.

CO Poisoning
#	– Smoke inhalation. – Defective heating systems. – Gas motors operating in poorly ventilated areas.
S/S	Mild-moderate: > Headache, confusion. > Malaise, dizziness, nausea. Severe: > Seizure, syncope, coma. > Myocardial ischemia, arrhythmias.
Dx	– ABG: carboxyhemoglobin level. – ECG ± cardiac enzymes.
Tx	– High-flow 100% oxygen. – Intubation/hyperbaric oxygen (severe).

Acute iron poisoning
Clx	– Abdominal pain, – hematemesis, diarrhea – Shock – Liver necrosis
Dx	– Anion gap met acidosis – Increased serum iron. – Radiopaque pills on abdominal x-ray
Tx	– IVF – Deferoxamine – Whole bowel irrigation

CYANIDE POISONING

Can be induced by Nitroprosside
hypoxia not responsive to supplemental O2
CNS: headaches / confusion / vertigo
PEx:

initially tachycardic and hypertensive → bradycardic and hypotensive
almond breath odor
pulmonary edema
flushing “cherry-red” skin

due to high venous oxyhemoglobin concentration
🏥: Lactic acidosis
DDx w/ CO poisoning? CO responds to O2.

Tx overview for suspected cyanide poisoning
Decontamination	Dermal Exposure: -Removal of clothing. -Skin decontamination. Ingestion: – Activated charcoal. All Exposures: – Antidote
Respiratory Support	No mouth-to-mouth resuscitation Supplemental oxygen Airway protection (intubation)
Cardiovascular Support	IVF for hypotension.

Methemoglobinemia

Presents with many similarities to CO poisoning.

Trigger: DAPSONE

Unlike carbon monoxide and cyanide poisoning,

it presents with cyanosis and bluish discoloration of skin and mucous membranes.

Methemoglobinemia treated with IV Methylene blue.

· Methemoglobin (Fe2+ → Fe3+)

· Fe3+ cant bine to oxygen, and it also increases the affinity of Fe2+ to oxygen, causing a left shift in the oxygen dissociation curve.

· Methemoglobinemia occurs after exposure to oxidizing agents (eg, dapsone, nitrates, topical/local anesthetics).

Toxic Alcohols
	Clx	Lab
Alcohol ketoacidosis	Slurred speech, unsteady gait, altered mentation.	High osmolar gap, increased anion gap metabolic acidosis due to ketosis
Methanol ingestion	Visual blurring, central scotomata, afferent pupillary defect, altered mentation.	High osmolar gap, increased anion gap metabolic acidosis
Ethylene glycol ingestion	Flank pain, hematuria, oliguna, cranial nerve palsies, tetany.	High osmolar gap, increased anion gap metabolic acidosis, calcium oxalate crystals in urine
Isopropyl alcohol ingestion	CNS depression, disconjugate gaze, absent ciliary reflex	High osmolar gap, but no increased anion gap and no metabolic acidosis

Acetaminophen Poisoning
Dx	· Measure level ≥4 hours, Not IMMEDIATELY · DONT GIVE N-Acetylcystine W/O DOCUMENTED HIGH ACETAMINOPHEN LEVEL (>10 g) or SIGNS OF HEPATIC FAILURE.
Tx	· 1˚ ABC Resuscitation · Gastric Lavage & Activated Charcoal · >8h: N-Acetylcystine (NAC)

Phenytoin Toxicity	Horizontal nystagmus, cerebellar ataxia, and confusion
Lithium	Tremor, hyperreflexia, ataxia, and seizures
True or False – Patients can be asymptomatic during first 24 hrs after acetaminophen OD.	Yes
Homeless man has calcium oxalate crystals in urine. Tx?	Ethylene glycol ingestion – Tx is Fomepizole* or ethanol (NOT methylene blue, which is Tx for methemoglobinemia)
what do u suspected in a pt with triad of hyperventilation, tinnitus, and GI irritation?	Aspirin Toxicity
Tx for cocaine intoxication	· Benzo · if not available: Aspirin, Nitroglycerin, and CCB
Similarities and differences w/ Ethylene glycol vs Methanol poisoning.	· Both can cause ANION GAP metabolic acidosis · Ethylene → kidney damage · Methanol → vision loss*
Use of Naloxone vs. Naltrexone	· Naloxone – used to Tx opioid overdose* · Naltrexone – 1st-line drug for alcoholism that improves abstinence rats by reducing craving for alcohol
Benzos OD can be distinguished from opioid OD by	lack of severe respiratory depression and lack of pupillary constriction
fever, flushing, altered mental status, dry mouth, and mydriasis with increased exposure to an anticholinergic (e.g., ipratropium and diphenhydramine), suggesting the diagnosis of antichoinergic toxicity,	physostigmine
acute methanol poisoning	intravenous fomepizole (1st line) or ethanol (2nd line).

Heat / Cold Emergencies

Posted on 30 July، 2019 Tagged ERLeave a comment

Exertional heat stroke
RF	– Strenuous activity during hot & humid weather. – Dehydration. – Poor acclimatization. – Lack of physical fitness. – Obesity. – Medications: Anticholinergics, antihistamines, phenothiazines. Tricyclics.
Clx	– Core temperature >40 C (104 F) immediately after collapse AND – Central nervous system dysfunction. Altered mental status, confusion, irritability, seizure. – Additional organ or tissue damage, RenalThepatic failure, disseminated intravascular coagulation. acute respiratory distress syndrome.
Tx	– Rapid cooling Ice water immersion preferred, can consider: high-flow cool water dousing, icelwet towel rotation, evaporative cooling. – Fluid resuscitation. – Electrolyte correction. – Management of end-organ complications. – No role for antipyretic therapy.

Clinical features of hypothermia
Classification	Mild: 32-35 C · Tachycardia, tachypnea. · Ataxia, dysarthria, increased shivering. Moderate: 28-32 C · Bradycardia, lethargy, hypoventilation, decreased shivering atrial arrhythmias. Severe: <28 C · Coma, cardiovascular collapse, ventricular arrhythmias.
Tx	General: · Warmed (42 C [107 F]) crystalloid for hypotension. · Endotracheal intubation in comatose patients. Rewarming techniques: · Mild hypothermia: Passive external warming (remove wet clothing, cover with blankets) · Moderate hypothermia: Active external warming (warm blankets, heating pads, warm baths) · Severe hypothermia: Active internal rewarming (warmed pleural or peritoneal irrigation, warmed humidified oxygen).

Frostbite
Clx	– Superficial pallor & anesthesia. – Blistering, eschar formation. – Deep tissue necrosis & mummification.
Tx	– Rapid rewarming in 37-39 C (98.6-102.2 F) water bath – Analgesia & wound care. – Thrombolysis in severe, limb-threatening cases.

Shocks

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Hemodynamic measurements in shock
#	Ⓝ	Hypovolemic	Cardiogenic	Septic
RA (preload)	4	↓	↑	Ⓝ
PCWP (preload)	9	↓	↑	Ⓝ
Cardiac index	2.8 – 4.2	↓	↓↓	↑
SVT (afterload)	1,150	↑	↑	↓
MvO2	60% – 80%	↓	↓	↑

Vitamin Deficiency

Posted on 30 July، 20198 August، 2019 Tagged ERLeave a comment

Water Soluble Vitamins
Vitamin	Source	Deficiency
B1 (thiamine)	Whole grains, meat, fortified cereal, nuts, legumes.	– Beriberi (peripheral neuropathy, heart failure). – Wemicke-Korsakoff syndrome.
B2 (riboflavin)	Dairy, eggs, meat, green vegetables.	– Angular cheilosis, stomatitis, glossitis. – Normocytic anemia. – Seborrheic dermatitis.
B3 (niacin)	Meat, whole grains, legumes.	– Pellagra (dermatitis, diarrhea, delusions/dementia, glossitis).
B6 (Pyridoxine)	Meat, whole grains, legumes, nuts.	– Cheilosis, stomatitis, glossitis, – Irritability, confusion, depression.
B9 (folate, folic acid)	Green leafy vegetables, fruit, meat, fortified cereal/grains.	– Megaloblastic anemia. – Neural tube defects (fetus).
B12 (cobalamin)	Meat, dairy.	– Megaloblastic anemia. – Neurologic deficits (confusion, paresthesias, ataxia).
C (ascorbic acid)	Citrus fruits, strawberries, tomatoes, potatoes, broccoli.	Scurvy (punctate hemorrhage, gingivitis, corkscrew hair).

Vitamins
Common causes?	· Alcoholics · Poor nutrition
B1 (Thiamine)	· Beriberi (Wet: HF / Dry: Peripheral neuropathy) · Wernikie-Korsakoff syndrome · W: Ataxia – Eye – AMS · K: Confabulation (irreversible)
B2	· Chelostomatitis · Cherry tongue · Normocytic Anemia · Seborrehic Dermatitis
B3	Pallegra
B6	· Peripheral neuropathy · depression · Cheilosis / Stomatitis
B9	· Macrocytic anemia · Neural tube defect
B12	· Macrocytic anemia · Dorsal column degeneration
C	Scurvy (Patechia / follicular hemorrhage / coiled hair / gum easy bleeding / depression)

Wernicke Encephalopathy
?	– Alcoholism. – Malnutrition (Anorexia nervosa). – Hyperemesis gravidarum.
Path	– Thiamine deficiency.
Clx △	– (AMS – EYE – ATAXIA). – Encephalopathy. – Oculomotor dysfunction (horizontal nystagmus, ⓑ abducens palsy). – Postural & gait ataxia.
Tx	IV thiamine followed by glucose infusion.

Scurvy
#	– Alcoholics/drug abusers, severely malnourished, – Poor fruit/vegetable intake. – Sx arise within 3 months of deficiency.
Sx	– Cutaneous – petechia, follicular hemorrhage, bruising, coiled hairs. – Gingival – bleeding/receding gums & dental carries. – Constitutional – arthralgias, weakness, malaise. – Depression. – Impaired wound healing. – Vasomotor instability (if severe/prolonged).
Dx	Serum ASCORBIC acid level
Tx	– Oral/injectable vitamin C resolves most Sx w/i days. – Toxicity can occur at high supplement levels (abdominal pain, diarrhea, nausea).

Pellagra is due to niacin deficiency and is characterized by the “3 Ds”: dermatitis, diarrhea, and dementia:

· Dermatitis is primarily on sun-exposed areas of the body and is characterized by rough, hyperpigmented, scaly skin.

· Diarrhea is often associated with abdominal pain, nausea, and loss of appetite.

· Dementia is due to neuronal degeneration in the brain and spinal cord and can lead to memory loss, affective symptoms (eg, depressed mood in this patient), and psychosis.

Niacin is present in a broad variety of foods and can be synthesized endogenously from tryptophan.

Causes:

alcoholism, chronic illness

Carcinoid syndrome (due to depletion of tryptophan)

Hartnup disease (congenital disorder of tryptophan absorption).

Prolonged isoniazid therapy

Fast HY Review

Tag: ER

Trauma

NECK TRAUMA

Spine Trauma

CHEST

Substance Abuse

Ingestions & Poisoning

Heat / Cold Emergencies

Shocks

Vitamin Deficiency