Toxicology
Ingestion of which of these is associated with delayed GI symptoms and hepatic failure?
A) Amanita mushroom
B) Poison hemlock
C) Oleander
D) Water hemlock
A
66 year old male presents with severe left-sided flank pain and urinary retention 2 days after starting chemotherapy for non-Hodgkin lymphoma. Workup shows a new acute renal failure along with hyperkalemia. Given the most concerning condition causing this clinical picture, what additional abnormal laboratory finding is most likely?
Hyperuricemia, hypocalcemia, hyperphosphatemia
What is the dose and route of epinephrine indicated for the treatment of anaphylaxis in adults?
0.3 mg IM
32 year old male presents with nausea and vomiting while vacationing in Florida. He says that his mouth and throat are tingling and prickly and that is hand burned when he tried to drink from a glass of ice water. He says that he ate seafood about 12 hours earlier. Most likely cause of his symptoms?
Ciguatera
Begin within 2-6 hours, resolves within 24 hours; can have CNS complaints like ataxia, vertigo, weakness; cold allodynia - pathognomonic sign of ciguatera poisoning - pain from normally well tolerated cold stimuli; another pathognomonic finding is return or worsening of symptoms with alcohol ingestion.
At what b-HCG level should you expect to be able to visualize an IUP?
1000 - 2000 via transvaginal US
An overdose of what pharmaceutical can cause an opioid like toxidrome?
Clonidine
What is the most common cause of acute chest syndrome in patient's with sickle cell disease?
C. pneumoniae and M. Pneumoniae
You are preparing to intubate a patient and your attending asks you how much etomidate and rocuronium you want to give?
20 mg Etomidate
70 mg Rocuronium
6 year old boy presents with fever of 3 days duration. Complained of back and abdominal pain for the past 2 weeks. Examination reveals adenopathy on the posterior cervical chain with normal appearing pharynx and scattered petechia on the boy’s trunk. Spleen tip is palpable and liver edge is palpated 2 cm below the costal margin. Most likely diagnosis?
A) Leukemia
B) ITP
C) Anemia
D) Infectious mononucelosis
A
You are asked to set up a defibrillator. How many joules do you start with for an unstable patient with A fib w/ RVR?
100 J can go up to 200 J if necessary
When considering physostigmine for the treatment of anticholinergic toxidrome, what is an absolute contraindication?
QRS widening
A 6 year old boy with a history of hemophilia A is brought in by his father 1 hour after sustaining a head injury. What is the first step in management?
Factor VIII therapy to 100% activity
Infusion of 1 unit of factor VIII per kg increases the level by approximately 2%, therefore the dose to get to 100% should be 50 units/kg.
GI & CNS bleeding require 100% activity level.
(kg) x 0.5 x percentage change in factor
A patient arrives via EMS after being rescued from a burning house and you evaluate him and note him to have 30% TBSA of burned skin. He is 70 kg. How much fluids are you ordering in the first 8 hours?
Parks formula: 4 ml x TBSA x weight in kg
4 x 30 x 70 = 8400 mL
Give 1/2 in the first 8 hours, 4.2 liters
34 year old woman with a history of leukemia presents with bleeding gums. She reports her menses have been heavier and longer than usual and that she is bruising easily. Approximately 2 weeks ago, her laboratory results were normal, but today, testing reveals Hgb 10g/dL, platelets 20,000/mcL, PT 17 seconds, PTT 30 seconds, low fibrinogen and elevated D-dimer. What is the diagnosis?
DIC
low platelets, prolonged coagulation times, elevated D-dimer, low fibrinogen levels
Causes fibrin formation and then breakdown; elevated D-dimer is often diagnostic of DIC
TX: treat underlying cause, supportive care, and prevention of bleeding with platelets or coagulation factors such as FFP
What is the most common cause of death after bariatric surgery?
A) PE
B) SBO
C) Anastamotic leak
D) Suicide
E) Pneumonia
Anastamotic leak
What are some indications for hemodialysis in the setting of acute salicylate poisoning?
altered mental status, serum level greater than 100 mg/dL at any time, serum level greater than 90 mg/dL in the setting of renal impairment, hypoxemia, and failure of standard therapies
25 year old man presents to the ED after taking an entire bottle of apixaban in a suicide attempt. While his vital signs are being obtained, he begins vomiting blood and requires intubation. What is the most appropriate treatment for this patient?
four factor PCC
Warfarin reversal - bleeding or high INR - Vitamin K/PCC
Heparin - protamine sulfate
Factor Xa inhibitor - andexanet alfa, PCC
Direct thrombin inhibitor - idarucizumab, PCC
TPA reversal - aminocaproic acid
Patient comes in and is actively seizing. IV access has not been established yet. What are you ordering?
Midazolam 10 mg IM
40 year old man presents via ambulance with confusion and fever. On examination, he is agitated, does not respond appropriately, and exhibits hyporeflexia. He is tachycardic, diaphoretic, and hypertensive with generalized rigidity. His temperature is 101.3. His medication list consists of haloperidol and clonazepam. What is the most likely diagnosis?
NMS
"lead pipe" rigidity
Complications - renal failure, seizures, pneumonia, DIC, death, arrhythmias
TX: discontinuation of the offending drug, IV fluids, temperature reduction with external cooling measures, sedation with benzodiazepines
Serotonin syndrome - hyperreflexia/clonus
Anterior-septal leads, V1-V3
Provide an example of a Crotalid that can be found in Florida/Southeast and what is the initial number of vials of the antidote you should give if indicated?
Cotton Mouth, Eastern Diamondback, Copperhead, Coral Snake
6 vials
Typically diluted in 250 cc or 1 L of normal saline and infused over an hour. Same dose for both adults and pediatrics (may have to adjust the dilution of CroFab for small children so that they are not volume overloaded). You can repeat dose (2 vials) at 6/12/ and 18 hours later if sx are not controlled
After trying to treat for anaphylaxis without success, you are now concerned for angioedema. What medications are you going to order?
TXA 1 gram
4 units FFP
FFP can replace the missing or deficient C1-INH which is crucial to regulating the inflammatory response that causes HAE (hereditary angioedema). FFP can worsen HAE in some cases.
You are handed an EKG that shows your patient is in SVT, BP is reassuring and vagal maneuvers have failed. What medication/dose are you ordering?
6 mg Adenosine. Repeat bolus of 12 can be given if necessary
29 year old patient presents with one day of severe lower abdominal pain and cramping associated with nausea and fever. For the past 2 weeks, they have had intermittent bloody/mucousy diarrhea, anorexia, and unintentional weight loss. Abdominal x ray show dilation of the transverse colon greater than 6 cm, loss of colonic haustrations, and thumbprinting from bowel wall edema. Diagnosis?
Toxic megacolon
You have a patient in status asthmaticus, in addition to albuterol, what are some other pharmacologic options to abort an asthma attack? What is the dose?
Methylprednisolone - 125 mg
Magnesium sulfate - 2 g IV over 20 minutes
Terbutaline - 0.25 mg subcutaneous every 20 minutes (maximum total dose 0.75 mg in 1 hour)
Epinephrine - 0.3 - 0.5 IM
Ketamine - IV bolus of 0.5-2 mg/kg followed by 0.5-3 mg/kg/hour as a continuous infusion
Heliox