Case 4 / Question #5 What is the next appropriate step in the management of this patient? a) intubation b) epinephrine 1 mg IV c) magnesium 1-2 g IV d) cardioversion at 100 J monophasic e) defibrillation at 360 J monophasic
Ventricular Tachycardia • Wide complex tachycardia + no pulse = unstable ventricular tachycardia • Defibrillation is the most appropriate next step, above managing airway or giving pressors. • Synchronized cardioversion not appropriate for unstable patient • Magnesium for torsades de pointes
Case 4 / Question #6 After the initial defibrillation, what is the next most appropriate step? a) start CPR, 2 minutes b) check for a pulse c) check the monitor, and administer another shock if needed d) administer epinephrine 1 mg IV
Case 4 / Question #6 After the initial defibrillation, what is the next most appropriate step? a) start CPR, 2 minutes b) check for a pulse c) check the monitor, and administer another shock if needed d) administer epinephrine 1 mg IV
CPR After Defibrillation • 2005 and 2010 AHA/ACLS guidelines emphasize uninterrupted chest compressions after defibrillation • Only after CPR should a pulse and monitor check be performed • Giving epinephrine should not delay resumption of CPR
Pulseless VT or VF • Check ABCs consider amiodarone 300mg IV • Defibrillation, immediate • Consider other drugs: CPR, then check rhythm lidocaine, magnesium • Intubation, establish IV • Think of H’s and T’s • Epinephrine 1mg IV/IO q3- • Remember the order: 5 mins SHOCK-CPR-CHECK • May substitute 1st or 2nd SHOCK-CPR-CHECK dose of epi with DRUGS vasopressin 40 U IV/IO • After 3 shocks/CPR,
Asystole or PEA • Check ABCs • Atropine REMOVED from algorithm! • Immediate CPR • No shocks, no pacing • Intubation, establish IV • Think of H’s and T’s • Epinephrine 1mg IV/IO q3- 5 mins • May substitute 1st or 2nd dose of epi with vasopressin 40 U IV/IO
H’s and T’s • Hypovolemia • Toxins Tablets • Hypoxia • Tamponade • H+ (acidosis) (cardiac) • Hyperkalemia • Tension PTX Hypokalemia • Thrombosis • Hypoglycemia (ACS or PE) • Hypothermia • Trauma
Case 5 • A 19 yo F with depression and multiple suicide attempts presents to hospital 1 hour following an ingestion of 30 tablets of Extra Strength Tylenol in a suicide attempt. • She denies any EtOH or illicit drug use. • Physical exam is unremarkable • The physician decides to administer activated charcoal.
Case 5 / Question #7 Which of the following oral overdoses will NOT benefit from activated charcoal administration? a) acetaminophen b) iron c) lorazepam d) levothyroxine
Case 5 / Question #7 Which of the following oral overdoses will NOT benefit from activated charcoal administration? a) acetaminophen b) iron c) lorazepam d) levothyroxine
Activated Charcoal • Highly adsorbant, inert material • Very large surface area that non-specifically binds to many substances • Decreases gut absorption by 75% if given within 1 hour • Do not give if patient cannot protect their airway
Activated Charcoal • NOT adsorbed by activated charcoal: • Alcohols • Hydrocarbons • Organophosphates • Acids • Potassium • Alkali • Iron • Lithium
Case 5 / Question #8 Activated charcoal is absolutely contraindicated in the treatment of toxic ingestions of: a) caustics (acids/alkalis) b) any substance if milk was co-ingested or administered c) lithium d) heavy metals e) digitalis
Case 5 / Question #8 Activated charcoal is absolutely contraindicated in the treatment of toxic ingestions of: a) caustics (acids/alkalis) b) any substance if milk was co-ingested or administered c) lithium d) heavy metals e) digitalis
Activated Charcoal • Acids/alkali ingestion are a CONTRAINDICATION. • AC does not absorb these and is ineffective in preventing tissue damage. • AC interferes with subsequent endoscopy, may cause vomiting and further caustic injury to esophagus / upper airway. • May be ineffective for lithium and heavy metals, but it is not contraindicated.
Case 5 / Question #9 If this patient adamantly refused to comply with drinking the activated charcoal, which of the following is true regarding your ability to administer charcoal? a) you cannot force the patient to take charcoal b) you must wait to get parental permission prior to treating her c) a court injunction is needed to force her to drink the charcoal d) after repeated attempts to get the patient to take charcoal, a nasogastric tube may be placed to facilitate treatment e) refusal to take charcoal orally is an indication for IV charcoal
Case 5 / Question #9 If this patient adamantly refused to comply with drinking the activated charcoal, which of the following is true regarding your ability to administer charcoal? a) you cannot force the patient to take charcoal b) you must wait to get parental permission prior to treating her c) a court injunction is needed to force her to drink the charcoal d) after repeated attempts to get the patient to take charcoal, a nasogastric tube may be placed to facilitate treatment e) refusal to take charcoal orally is an indication for IV charcoal
Suicidal Patients • Suicidal patients do not have the right to refuse potentially life-saving care. • Physicians may do what they need to do in an effort to save the patient. • In emergencies, parental permission for treatment is unnecessary.
Case 5 • 19 yo F with acetaminophen overdose, normal exam • EKG unremarkable • Urine pregnancy negative • Chemistries and LFTs unremarkable • Acetaminophen level = 175 micrograms/mL
Case 5 / Question #10 Which of the following statements about acetaminophen ingestion is TRUE? a) serial LFTs are indicated in all acetaminophen ingestions b) renal sequelae are expected c) IV N-acetylcysteine (NAC) is safer than oral NAC d) an acetaminophen level drawn 4 hours post-ingestion dictates need for antidotal therapy
Case 5 / Question #10 Which of the following statements about acetaminophen ingestion is TRUE? a) serial LFTs are indicated in all acetaminophen ingestions b) renal sequelae are expected c) IV N-acetylcysteine (NAC) is safer than oral NAC d) an acetaminophen level drawn 4 hours post-ingestion dictates need for antidotal therapy
Acetaminophen Toxicity • An acetaminophen level drawn at hours 4-20 can be plotted on the Rumack-Matthew nomogram to guide therapy based on hepatic toxicity.
Acetaminophen Overdose • Liver function tests are not indicated for trivial acetaminophen ingestions, but may be useful in severe ingestions. • One potential side effect of IV NAC is an anaphylactoid reaction.
Case 6 A 32-yo man presents 30 minutes after getting a tooth knocked out in a fight. On examination, a small clot in the socket is noted. He has the intact tooth with him wrapped in tissue.
Case 6 / Question #11 A 32-yo man presents 30 minutes after getting a tooth knocked out in a fight. On examination, a small clot in the socket is noted. The next step in management is: a) call the patient’s dentist b) clean the tooth with a brush c) gently irrigate the socket d) immediately replace the tooth e) tell the patient the tooth cannot be reimplanted
Case 6 / Question #11 A 32-yo man presents 30 minutes after getting a tooth knocked out in a fight. On examination, a small clot in the socket is noted. The next step in management is: a) call the patient’s dentist b) clean the tooth with a brush c) gently irrigate the socket d) immediately replace the tooth e) tell the patient the tooth cannot be reimplanted
Tooth Avulsion • Avulsed teeth should be reimplanted as quickly as possible. • Although little preparation is needed to ready the socket for reimplantation, clots should be removed with gentle saline irrigation • Avoid other manipulation of the socket, if possible.
Tooth Avulsion • Reimplantation is possible within 2 to 3 hours. • The avulsed tooth should be rinsed with saline or tap water to remove debris before implantation. • The avulsed tooth should not be scrubbed as this may injure the periodontal ligament, which might still be attached to the tooth. • Early improper tooth reimplantation is better than delayed reimplantation by an oral surgeon.
Tooth Avulsion H&P 1. Where is the tooth? 2. How old is the patient? 3. How long has the tooth been out? (periodontal ligament cells die within 60 minutes outside the oral cavity) 4. Is there other significant maxillofacial trauma?
Case 7 • A 50 yo F presents with diffuse tongue swelling and hoarse voice that began shortly before arrival. • Now she is drooling, dyspneic, and can barely talk. • She has hypertension and is on lisinopril and hydrochlorothiazide. She has not eaten new foods, used any new toiletries, clothing, or medications.
Case 7 / Question #12 Which of the following medications would be most efficacious to treat this condition? a) cetirizine b) diphenhydramine c) epinephrine d) methylprednisolone e) dexamethasone
Case 7 / Question #12 Which of the following medications would be most efficacious to treat this condition? a) cetirizine b) diphenhydramine c) epinephrine d) methylprednisolone e) dexamethasone
Angioedema • Severe allergic reactions range from urticaria to angioedema to anaphylaxis. • In patients with airway compromise from angioedema, IM epinephrine is indicated. • Epinephrine-induced catecholamine release causes vasoconstriction to reduce periglottic edema and improve patency. • Epinephrine also increases systemic vascular resistance to maintain blood pressure in anaphylactic shock.
Angioedema • Nonpruritic edema of submucosa, usually involving tongue, lips, and face • Reaction involves the dermis • Have a high degree of suspicion for airway compromise, consider laryngoscopic evaluation • Treatment: • IM epinephrine (0.3-0.5 cc of 1:1000) for impending airway compromise • Early airway protection with intubation for intraoral, pharyngeal, and lingual involvement
Urticaria • Allergic reaction involving the epidermis and presents with pruritic, erythematous, raised wheals of the skin. • Treatment is mainly supportive: • Removing the offending agent, cold compresses • H1 blockade/antihistamines • H2 blockers added for severe or refractory sx • Corticosteroids for severe or refractory symptoms (use short course)
Anaphylaxis • Severe systemic hypersensitivity reaction • Multisystem involvement, manifested by hypotension or airway compromise • Look for bronchospasm, voice changes and stridor from laryngeal edema, drooling • Treatment is same as urticaria/angioedema, but also consider: • Intubation for unstable patients, vasopressors • Usual ACLS resuscitation
Case 8 • A 22 yo M presents with a “spider bite,” after he was cleaning his garage. • He developed crampy muscle aches that spread up his arm initially. Now he has abdominal cramping, nausea, and dizziness. • He has a rigid abdomen on exam.
Case 8 / Question #13 Which of the following spiders can cause this presentation? a) tarantula b) hobo spider c) brown recluse spider d) wolf spider e) black widow spider
Case 8 / Question #13 Which of the following spiders can cause this presentation? a) tarantula b) hobo spider c) brown recluse spider d) wolf spider e) black widow spider
Black Widow Spider Bite • Classically present with an initial pinprick sensation followed by a mild local inflammatory response (<1 hr) • Then crampy mylagias at the bite site spreading up the extremity • Myalgias eventually involve the entire body; patient may present with a rigid abdomen which is difficult to differentiate clinically from peritonitis
Black Widow Spider Bite • Treatment is supportive • Opioids and benzodiazepines for pain and muscle spasms • Calcium gluconate found NOT to be effective • Antivenom may be an option in severe cases
Brown Recluse Spider Bite • Causes dermal necrosis and black eschars which are self-limited • Rarely may cause DIC and hemolysis • Treatment is supportive
Case 9 • A 20-yo M with no PMHx comes to your office after being bitten on his left forearm by his neighbor’s cat only 2 hours ago. • There is no bleeding, no swelling, and the patient is neurovascularly intact.
Case 9 / Question #14 Which of the following statements regarding bite wounds is correct? a) cat bites are most commonly polymicrobial b) cat bites do not require prophylactic antibiotics unless there is a foreign body in the wound c) mammal bites are not tetanus-prone wounds d) only 5-6% of dog bites ultimately become infected
Case 9 / Question #14 Which of the following statements regarding bite wounds is correct? a) cat bites are most commonly polymicrobial b) cat bites do not require prophylactic antibiotics unless there is a foreign body in the wound c) mammal bites are not tetanus-prone wounds d) only 5-6% of dog bites ultimately become infected
Animal Bite Wounds • Dog Bites • Polymicrobial and may involve Pasturella , but not usually P. multocida . • Only 5-6% of dog bites become infected (about the same for nonbite lacerations). • Wounds involving the hand and high-risk patients are more likely get infected • Cat bites • Become infected 60-80% of the time and thought to be related to virulent strains of P. multocida .
Bite Management Principles • Assess for life-threatening bites (vascular, bites on the neck) • Examine for joint / tendon involvement • Emphasis on wound cleaning • X-ray if foreign body is suspected • Don’t close hand/foot bites, puncture -type bites, bites > 6 hrs, & contaminated wounds
Dog Bite Treatment • Uncomplicated dog bites do not routinely need prophylactic antibiotics • EXCEPTION: immunocompromised patients (alcoholic liver disease, asplenia, chronic steroid use) • risk of sepsis from C. canimorsus (with gangrene, purpura, petechiae) • Amoxicillin/clavulanate for 5-7 days alternatives: fluroquinolone (moxifloxacin), doxycycline • Tetanus toxoid
Cat Bite Treatment • All cat bites should receive prophylactic antibiotics • Amoxicillin/clavulanate for 5-7 days • PCN, amoxicillin, cefuroxime, doxycycline will cover P. multocida
Human Bite Treatment • Treat all human bites as contaminated puncture wounds • Usually polymicrobial ( Staph and Strep species, Eikenella , anaerobes) • Amoxicillin/clavulanate for 5-7 days
Case 10 • A 35 yo M presents with blistered burns to the anterior halves of both his thighs and legs after spilling scalding water. • He is in severe pain.
Case 10 / Question #15 What is the total body surface area (TBSA) of a man who presents with blistered burns of the anterior halves of both his thighs and legs? a) 9% b) 18% c) 27% d) 36%
Case 10 / Question #15 What is the total body surface area (TBSA) of a man who presents with blistered burns of the anterior halves of both his thighs and legs? a) 9% b) 18% c) 27% d) 36%
The Rule of Nines Head - 9% Chest - 18% Back - 18% Each Leg - 18% Each Arm - 9% Perineum - 1%
Burns Classifications Depth Appearance Sensation Healing Time Dry, red Superficial Painful 3-6 days Blanching Blisters Superficial partial- Moist, red, weeping Painful to temperature/air 7-21 days thickness Blanching Blisters > 21 days Deep partial- Wet or waxy, white or red Pressure only Usually requires surgical thickness Non blanching treatment Waxy, leathery, dry Rare, unless surgically Full-thickness White or grey Deep pressure only treated Non blanching Extends into fascia or Never, unless surgically Fourth degree Deep pressure only muscle treated
Burn Unit Admission • Burns of face, hand, feet, genitalia, perineum, major joints • Electrical burns • Chemical burns with potential for cosmetic/functional impairment • Significant inhalation injury • Co-morbid disease • Partial thickness burns >10% TBSA • Full thickness burns in any age group
Parkland Formula 4cc Ringers lactate per %TBSA burn per kg body weight 1/2 of total in first 8 hours 1/2 in second 16 hours
Pearls in Burn Cases • Consider carbon monoxide poisoning • Look for singed nasal hairs, carbonaceous sputum, and facial burns as markers for potential airway edema and obstruction • Look for circumferential burns • Prophylactic antibiotics are not indicated in burns
Case 11 • A 13 yo M with no PMH presents with parents with left thigh pain for 1 week starting the day after football practice. No relief with OTC meds. • Mostly painful with running. • On exam, he is obese, has an antalgic gait, and decreased/painful internal ROM of the left hip. • Thigh and knee exams are normal.
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