Antidotes/Reversal Agents
Treatment for CHOLINERGIC toxidrome
Atropine! +/- pralidoxime
Typical symptoms: salivation, Lacrimation, Urination, Diarrhea, Emesis, GI cramping, Weakness, Hypertension, Tachycardia, and Muscle fasciculations
Common boards presentation: organophosphates or pesticide exposure
Don't forget the "Killer B's": bronchorrhea, bronchospasm, bradycardia
5 yo child presenting with bilateral lacy rash on his cheeks, giving a "slapped" appearance. Most likely dx?
5th disease (erythema infectiosum)
Caused by parvovirus B19
Key points: Fairly benign, but dangerous in pregnant women (associated with hydrops fetalis), sickle cell disease (aplastic crisis) or immuno-compromised
Patient presents shortly after eating some fish at a restaurant that had a very "peppery" taste. Notes skin flushing as well as several episodes of vomiting. What do they likely have?
Scromboid
Seen with tuna, mahi mahi, blue fish, mackerel
Presentation:
º Meal described as peppery
º Histidine broken down to histamine and leads to rapid onset of skin flushing (skin /torso), gastroenteritis
Supportive: antihistamines, bronchodilators
Patient presents with a painful bite that he sustained while cleaning his outdoor shed with a target lesion. Upon presentation, patient also having diffuse muscle spasms.
Lactrodectus mactans (black widow) spider - hourglass on abdomen
- Toxin effects: induces ACh/NE release
- Other symptoms include pain (abdominal, local, back, can mimic surgical abdomen), hypertension, tachycardia, diaphoresis
- Treat with benzos, narcotics
- Antivenom available if life threatening
What reflex is associated with S1?
Reversal agent for heparin?
Protamine
3 yo girl presents with significant itching and discomfort. On exam, you notice erythematous vesicles in various stages of development. You find out that she has not been vaccinated. Most likely diagnosis?
Chicken pox (varicella zoster)
Key Points:
º More severe in adults than children
º Dormant infection can lead to herpes zoster
º Dangerous in pregnancy
Malaria-like illness including flu-like symptoms, hemolytic anemia, thrombocytopenia after being bitten by a tick?
Babesiosis (Babesia microti)
Vector: Ixodes scapularis tick
Treatment: Atovaquone and azithromycin, or clindamycin and quinine
Child presents with a hemorrhagic bullae with a eschar beneath that developed a few days after playing in the attic. The patient has fevers and acute renal failure. What bit the patient?
Loxosceles reclusa (brown recluse) spider – violin shaped mark on back
- Toxin effects: local tissue damage
- Can leave ulcer after eschar slough offs
- Systemic manifestations are very uncommon, but more likely in children (fever, hemolysis, DIC, renal failure)
- Treatment: update tetanus, debride after erythema subsides, no dapsone, +/- steroids
What reflex is associated with L2, L3, L4?
Patellar reflex
A patient presents after consuming their entire bottle of their diabetes medications. What medication/treatment should be used with sulfonylureas specifically?
Octreotide
- to prevent insulin secretion and maintain euglycemia
4 yo unvaccinated M presents with a few days of cough, red eyes and rash that initially presented on his face, but has since worsened. On exam, you notice red maculopapular pruritic rash that per report started on his face and has since spread down to his trunk and extremities. Most likely diagnosis?
Measles (Rubeola)
Key Points:
º A leading cause of death among children globally
º Vaccine available in US
º Cough, congestion, coryza, Koplik spots
Tick related illness that presents as a petechial rash starting on the palms and soles
Rocky Mountain Spotted Fever (Rickettsia rickettsii)
Vector: American dog tick
Symptoms: Fever, headache, abdominal pain, vomiting, rash
Treatment: doxycycline
Bites from what type of snake cause local tissue damage and hematologic toxicity?
Crotalids/Viperidae (rattlesnakes, etc) – triangular/
diamond shaped heads and elliptical pupils
Symptoms:
º Proteases break down tissue and cause coagulopathy by causing fibrinolysis and platelet damage
º Leads to elevation in PT/INR, fall in platelets, fall in fibrinogen
Treatment: Crotalidae antivenom (CroFab) only if they have evidence of envenomation
What reflex is associated with C5, C6?
Brachioradialis
Treatment for ANTI-CHOLINERGIC toxidrome
Benzos, physostigmine
Common symptoms: altered mental status (confusion, agitation), dry flushed skin, dilated pupils, tachycardia, hyperthermia, urinary retention, and possibly hallucinations
Common presentation: patient with exposure to antihistamines, parkinsons meds, antispasmodics, jimson weed, deadly nightshade
A 9 yo F presents with her mother with concerns for diffuse rash on her body. Mother reports that she was sick a little bit ago with a sore throat but that has since resolved. Most likely diagnosis?
Scarlett Fever
Caused by strep pyogenes
Described as a sandpaper (fine maculopapular) rash
Key points:
º Follows streptococcal infection and caused by toxin release
º Associated with glomerulonephritis and rheumatic heart disease
Patient presents shortly after eating some fish with perioral tingling, vomiting and odd temperature sensations that they can't quite describe. Likely toxin?
Ciguatera
Seen with dinoflagellates (grouper, barracuda, red snapper)
Onset within 6 hours, gastroenteritis, “hot/cold” reversal, paresthesia, myalgia, weakness, “loose teeth,” bradycardia, respiratory arrest
Treatment: symptomatic
A patient presents to the ED with numbness, palsies, and paralysis after a snake bite. What bit the patient and what are the next steps?
Elapidae (coral snakes)
*red on yellow kill a fellow*
- Toxin effects: neurotoxic
- Symptoms: numbness, palsies, paralysis
- Next steps: mandatory admission, wait for respiratory symptoms before antidote
What reflex is associated with C5, C6?
Biceps reflex
Your patient presents after accidentally spilling hydrofluoric acid on their hand while at work. What topical agent should be applied to the affected area?
Calcium gluconate gel
it effectively neutralizes the fluoride ion released by the acid, preventing further tissue damage by binding to the calcium in the skin and essentially stopping the destructive process that causes severe pain and tissue necrosis
Rash that typically appears AFTER a few days of high fever
6th Disease (roseola, exanthem subitum)
Erythematous nonpruritic rash following fever that
begins on the trunk and extends to extremities
Tick illness that can cause ulceration at site of bite
Tularemia (Francisella tularensis)
Vector: Dog tick
Treatment options: streptomycin, gentamicin, doxycycline, or ciprofloxacin
A patient presents with a sting from an unknown bug/animal with opsoclonus, fasciculations, and difficulty swallowing. What bit the patient and what are the next steps?
Scorpion (Centruroides)
- Toxin effects: neurotoxic, causes release of acetylcholine and catecholamines
- Symptoms: CNS- opsoclonus, slurring, blurry vision, difficulty swallowing, fasiculations
- Treatment is supportive: benzos, NSAIDs, antivenom
What reflex is associated with C6, C7?
Triceps