In Excess of
A 45-year-old woman with a history of bipolar disorder presents to the ED with nausea and vomiting. On exam, her vital signs are within normal limits, but she is confused. Laboratory studies are notable for a lithium level of 5.6 mEq/L and creatinine of 1.9 mg/dL. What is the best next step in management?
a) administer lasix for forced diuresis
b) administer lithium specific antibody fragments
c) consult hematology for emergent plasmapheresis
d) consult nephrology for emergency hemodialysis
d) consult nephrology for emergent hemodialysis
Indications for HD in Li overdose:
Li lvl >5
>4 with impaired renal function
Presence of severe symptoms (seizure, dysrhythmia, etc.)
Elevated Li lvl in a patient with contraindication to large fluid administration (CHF, etc.)
Which of the following laboratory findings is consistent with a diagnosis of isolated isopropyl alcohol toxicity?
a) pH 7.1, sodium 136 mEq/L, potassium 4.2 mEq/L, chloride 100 mEq/L, and bicarbonate 12 mEq/L
b) pH 7.2, sodium 140 mEq/L, potassium 4.2 mEq/L, chloride 110 mEq/L, and bicarbonate 22 mEq/L
c) pH 7.4, sodium 135 mEq/L, potassium 4.0 mEq/L, chloride 99 mEq/L, and bicarbonate 24 mEq/L
d) pH 7.5, sodium 137 mEq/L, potassium 3.7 mEq/L, chloride 103 mEq/L, and bicarbonate 30 mEq/L
c) pH 7.4, sodium 135 mEq/L, potassium 4.0 mEq/L, chloride 99 mEq/L, and bicarbonate 24 mEq/L
Isopropyl alcohol makes up 70% of rubbing alcohol
Acetone is the active metabolite, acid-base neutral, not very toxic
No indication for fomepizole in isopropyl alcohol ingestion
Which of the following is characteristic of a brown recluse spider bite?
a) Hypertension and tachycardia
b) Muscle cramping extending to the trunk, back, and abdomen
c) Painless bite
d) Target lesion with blanched center and surrounding erythema
c) Painless bite
The others all describe Lactrodectus envenomation (Black Widow)
Brown Recluse bites eventually become painful, but that is due to the delayed effects of the coagulation necrosis that occurs due to the venom
An 18 year-old male presents from a party unresponsive with a GCS. BP 110/65, HR 40, SPO2 83% ORA, RR 10, T 36 C. BGL 75. Police inform you that his friends had put a small amount of a "date rape drug" called gamma-hydroxybutyric acid (GHB) in his beer as a joke that went too far. Which of the following is the best next step in management of this patient?
a) prepare for intubation
b) administer atropine
c) start an isoproterenol infusion
d) administer dextrose followed by insulin at 1U/KG
e) administer sodium bicarbonate
f) administer high-dose iV naloxone
a) prepare for intubation
There is no cure or reversal agent for GHB. It is analogous to baclofen.
Patients often present with coma, then spontaneously regain consciousness, often days to weeks later.
Supportive care only (airway stabilization, IVF resuscitation, vasopressors as needed)
In fly fishing terms, what does sight-fishing refer to?
a) Using a rife-sight on the fly rod to more accurately cast
b) Using polarized sunglasses to reduce glare, allowing yourself to better visually track your fly in the water
c) The act of using a sight hound breed, such a Silken Windhound, to stalk and spot fish to then cast to
d) The act of stalking a rising fish or easily visible fish in clear water to strategically position yourself out of their line of sight, allowing for a targeted cast in their feeding lane
d) The act of stalking a rising fish or easily visible fish in clear water to strategically position yourself out of their line of sight, allowing for a targeted cast in their feeding lane
Other Sight Hound breeds include Greyhounds, Whippets, Borzois, Salukis, and Irish Wolfhounds
These are traditional hunting breeds known for their eyesight and great speed to chase prey
A 45-year-old man weighing 70 kg presents to the ED after intentionally ingesting 70 tablets of regular-strength aspirin approximately 5 hours ago. He is diaphoretic and nauseated. His blood pressure is 150/80 mm Hg, heart rate is 110 bpm, respiratory rate is 32/min, and temperature is 38.6°C. Initial laboratory studies are pending. Which of the following is an indication for immediate hemodialysis in this patient?
a) ASA level of 50
b) Ibuprofen coingestion
c) Seizure
d) Serum pH of 7.25
c) Seizure
Indications for HD in ASA Poisoning:
ASA lvl >=100, or >= 40 in chronic ingestion
Rapidly rising ASA lvl
AMS (including seizure, suggests cerebral edema)
Kidney or liver failure
Pulmonary edema
Severe acid-base abnormality
A 5-year-old boy is brought to the emergency department for altered mental status. The family had a party at their house the night before. In the morning, they found their son on the floor, surrounded by empty cans of beer. He appears sleepy, and on the way to the hospital, he vomited twice. On examination, the boy is sedated, with sluggish pupils and flushed skin. Which of the following abnormalities would you expect with the patient’s toxic ingestion?
a) Abnormal findings on head CT
b) Hyperkalemia
c) Hyperthermia
d) Hypoglycemia
e) Metabolic alkalosis
d) Hypoglycemia
Decreased blood glucose < 40 mg/dL is well described in children who have ingested ethanol. This ethanol-induced hypoglycemia results from exhausted glycogen reserves.
Which of the following marine exposures is correctly paired with the appropriate treatment?
a) Jellyfish nematocysts and fresh water rinsing
b) Sponge dermatitis and oral antibiotics
c) Stingray injuries and hot water immersion
d) Tetrodotoxin poisoning and hot water immersion
e) Stonefish envenomation and urinating on wound
c) Stingray injuries and hot water immersion
The tail cuts and injects venom into the laceration
Treatment consists of cleansing, tetanus prophylaxis, and hot water immersion for 60-90 min or until the pain subsides- 110-114 degrees F recommended
The hot water is thought to denature the venom proteins
Jellyfish = vinegar; Sponge = antihistamine +/- topical steroids; Tetrodotoxin (pufferfish, blue ringed octopus) = supportive care; Stonefish = antivenom
Which of the following is an indication for deferoxamine in the treatment of iron overdose?
a) ingestion of 15 mg/kg elemental iron
b) ingestion of 25 mg/kg elemental iron
c) iron level of 350 mcg/dL with AG metabolic acidosis
d)Iron level 450 mcg/dL in an asymptomatic pt
c) iron level of 350 mcg/dL with AG metabolic acidosis
There is no weight-based toxic dose
Indications for deferoxamine:
Iron level >500 mcg/dL
Shock
Acidosis
AMS
Severe refractory GI sx (UGIB, uncontrolled vomiting, etc.)
A 72-year-old man presents with headache, eye pain, and photophobia. He had cataract surgery 6 days ago. On examination, his visual acuity is decreased in the affected eye. His eye examination shows a white material layering in the anterior chamber with diffuse conjunctival injection. What is the best next step in management?
a) Emergency ophthalmologic consultation
b) Orbital computed tomography scan
c) Topical ciprofloxacin
d) Topical dexamethasone
a) Emergency ophthalmologic consultation
This describes endophthalmitis, an infection of the chambers of the eye (anterior, posterior, and vitreous). Most often following ocular surgery, within 1 week. Typically a Strep infection.
What aspect of the physical examination can best distinguish an anticholinergic toxidrome from a sympathomimetic toxidrome?
a) Pupils
b) Skin
c) Temperature
d) Heart rate
b) Skin
Anticholinergic toxidrome associated with anhidrosis/abnormally dry skin, sympathomimetics associated with diaphoresis
A 2-year-old boy is brought to the ED by his parents after chewing on a single pellet of brodifacoum-containing rat poison 4 hours prior to arrival. The child is otherwise healthy and has had no symptoms. Vital signs and physical exam are within normal limits. Which of the following is the best next step in management?
a) administer activated charcoal
b) discharge and follow up coags in 48 hours
c) give IV protamine
d) give oral vitamin K
c) give IV vitamin K
b) discharge and follow up coags in 48 hours
Rat poison contains long-acting anticoagulation with MOA very similar to warfarin
Small ingestions (1-3 pellets) are rarely toxic, toxicity can be ruled out at 48 hr with normal range INR)
A 12-year-old girl presents to the emergency department with a painful leg. She was playing in a leaf pile in the yard when she felt immediate pain to her right leg. On exam, she looks uncomfortable and in pain. Her physical examination reveals a painful swollen region of confluent erythema with a pinpoint, red dot in the center involving the right anterior ankle. What is the most appropriate initial treatment?
a) Epinephrine, diphenhydramine, famotidine, and prednisolone
b) Ice pack and diphenhydramine
c) Latrodectus antivenom and observation
d) Prophylactic antibiotics and nonsteroidal anti-inflammatories
b) Ice pack and diphenhydramine
Hymenoptera envenomation (wasps, bees) can mimic cellulitis, but avoid antibotic prophylaxis
A 30 yo F with history of depression presents in extremis after her family found her encephalopathic with an empty pill bottle on her nightstand. They didn't bring the bottle or take a picture of it because they correctly assumed that you would be a competent physician who doesn't need all the answers to arrive at the correct diagnosis. Her ECG is shown. What is the correct medication to administer to this patient?
a) Digifab
b) Sodium bicarbonate
c) NAC
d) Deferoxamine
e) Physostigmine
b) Sodium bicarbonate
TCA OD
EKG with widened QRS and terminal R wave in aVR
How do you distinguish herpes simplex virus (HSV) keratitis from herpes zoster ophthalmicus (HZO) on eye exam?
a) HSV has terminal bulbs on dendrites, zoster does not
b) HZO involves numerous punctate lesions
c) HSV keratitis spares the limbus
d) HSV keratitis is accompanied by vesicles at the tear duct
a) HSV has terminal bulbs on dendrites, zoster does not
HSV keratitis involves "true" dendrites (with terminal bulbs), while HZO produces pseudodendrites
For which ingested agent is it most appropriate to administer activated charcoal within 1 hour of ingestion?
a) ethylene glycol
b) lithium
c) iron
d) sodium hydroxidde
e) aspirin
e) aspirin
Alcohols are absorbed rapidly
Metals have very low binding affinity for charcoal
Charcoal is contraindicated in caustic ingestion due to risk of precipitating vomiting which puts tissues at high risk of perforation
A 4-year-old boy is brought to the ED by his parents after they found him in the backyard shed choking and gagging. Before this event, he was otherwise healthy. His temperature is 101°F (38.3°C), heart rate is 95 bpm, blood pressure is 100/60 mm Hg, and respiratory rate is 40/min. On exam, he appears sleepy but continues to cough. Pulmonary findings include moderate retractions and diffuse wheezes. A chest X-ray shows patchy infiltrates. What is the most likely diagnosis?
a) Anaphylaxis
b) Botulism
c) Hydrocarbon ingestion
d) Organophosphate ingestion
c) Black widow envenomation
c) Hydrocarbon ingestion
lamp oil, gasoline, light fluid, etc.
Only need as little as 1 mL for pneumonitis (respiratory distress, fever, patchy infiltrates on CXR)
A 22-year-old man presents after encountering a Portuguese man-of-war in the ocean. He reports significant stinging to his leg with some paresthesias. Which of the following has been shown to be most effective to neutralize additional nematocysts?
a) Cold fresh water
b) Hydrogen peroxide
c) Human urine
d) Salt water
e) Vinegar
f) The urine of the rare Mongolian snow leopard
d) Salt water
While vinegar works best for most jellyfish, the Portuguese Man-of-War is an exception
Avoid fresh water! It actually causes more nemocyst toxin release
Fun Fact: In researching this question, I learned that Mongolia is home to the world's second largest population of snow leopards
BONUS 100 POINTS: Which country is home to the largest population of snow leopards?
A 79-year-old woman with a history of atrial fibrillation who is on warfarin is sent to the ED from her primary care clinician’s office after a routine outpatient blood draw revealed an INR of 11. The patient reports she is feeling in her normal state of health. She reports no bleeding, headache, chest pain, or lightheadedness. Her temperature is 98.6°F (37.0°C), blood pressure is 120/80 mm Hg, heart rate is 75 bpm, respiratory rate is 18/min, and oxygen saturation is 100% on room air. What is the best next step in management?
a) administer 4-Factor PCC
b) administer TXA
c) administer vitamin K 10 mg IV
d) administer vitamin K 5 mg orally
e) discharge the pt with f/u with PCP in 48 h
d) administer vitamin K 5 mg orally
INR > 10 WITHOUT active bleeding = Vitamin K orally and stop warfarin
INR > 10 WITH active bleeding = Vitamin K IV, stop warfarin, 4F PCC
INR < 10 WITHOUT bleeding = +/- oral vitamin K 2.5 mg (if >4.5) based on bleeding and thromboembolism risk
A 58-year-old man presents with vision loss in his left eye. He first noticed the symptoms when he woke up this morning. He reports no pain. A dilated funduscopic examination is performed and shows diffuse retinal hemorrhages, cotton-wool spots, dilated and tortuous retinal veins, and retinal edema. Which of the following is a risk factor for developing the most likely condition?
a) aspirin use
b) Chronic glaucoma
c) Contact lens use
d) Marfan syndrome
b) Chronic glaucoma
Central retinal vein occlusion results in sudden, painless monocular vision loss
Other risk factors include advanced age, hypertension, diabetes mellitus, hyperlipidemia, atherosclerosis, chronic glaucoma, blood dyscrasia, clotting disorders, vasculitis, autoimmune disorders, tobacco use, and oral contraceptive use
A 75-year-old man presents with altered mental status for 1 day. His vital signs on arrival are a T of 103.1°F (39.5°C), HR of 140 bpm, RR of 30/min, and BP of 180/100 mm Hg. His physical examination is notable for diaphoresis, midrange reactive pupils, and rigidity. His ECG shows sinus tachycardia. He is confused and unable to answer questions. Which of the following medication withdrawals is the most likely cause of his symptoms?
a) Amitriptyline
b) Clonidine
c) Fluoxetine
d) Levodopa
d) Levodopa
Levodopa withdrawal in a patient with parkinsons is indistinguishable from NMS and therefore requires a thorough history to make the diagnosis
The levodopa should be given promptly, along with supportive care measures
A 4-year-old boy presents to the emergency department by EMS after a potential toxic ingestion. He is somnolent on arrival but tachypneic. A strong odor of wintergreen is noted. Which of the following is the most likely arterial blood gas for this patient?
a) pH 7.00, PCO2 28, bicarb 12
b) pH 7.30, PCO2 12, bicarb 6
c) pH 7.40, PCO2 40, bicarb 24
d) pH 7.48, PCO2 30, bicarb 22
b) pH 7.30, PCO2 12, bicarb 6
Metabolic acidosis (pH7.30, bicarb 6) with respiratory acidosis (PCO2 12)
Winter formula: (expected PCO2 = 1.5 × bicarbonate + 8 ± 2) = 1.5 x 6 + 8± 2 = 15 to 19
12 is abnormally low, more than compensation
Oil of wintergreen is meant to be topical only
A 3 year-old girl presents with acute foot pain that started while walking barefoot outside in her backyard. BP 90/palp, HR 176, T 38.1 C, SPO2 97% ORA. On exam she appears restless with copious oral secretions, jerking movements of her arms and legs, and roving eye movements. Foot examination is unremarkable. Which if the following envenomations most likely explains her symptoms?
a) Black widow bite
b) Arizona Bark Scorpion sting
c) North Southwestern Coral Snake mauling
d) Eastern Coral snake bite
e) Pit viper bite
f) Fire ant bite
b) Arizona Bark Scorpion sting
Centruroides spp. envenomation contains toxin that activates both the sympathetic (tachycardia and fever) and parasympathetic (secretions, muscle fasciculations) nervous systems
Antivenom exists, only in AZ, reserved for severe envenomations, which are very rare
A 50 year old male is found in his garage where his wife reports he was cleaning some rusty horseshoes with a GCS of 9. His hand is mottled and has a pruned appearance to the skin. There was a spilled bucket containing the horseshoes and a liquid. He is confused and smells of urine and will not open his eyes. There is a tongue laceration. BP 130/95, HR 80, SPO2 88% ORA. His EKG is shown. In addition to suplemental O2 and IV access, what is the best next step in management?
a) Load with 40 mg/kg of Keppra
b) Load with 60 mg/kg of Keppra
c) administer 2 g calcium gluconate
d) administer 2 g of Magnesium Sulfate
e) Activate the cardiac cath lab
d) Consult nephrology for emergent HD and place a trialysis catheter
c) administer 2 g calcium gluconate
Hydrofluoric acid toxicity
HF found in rust removers, glass etching supplies
Causes HYPOcalcemia, HYPOmagnesemia, and HYPERkalemia
While Mg should also be given, the HYPOcalcemia leads to seizures and the HYPERkalemia leads to ventricular dysrhythmias, with Ca2+ being the antidote or stabilizing agent of both of those
Fluke is a delicious game fish found in the marine waters of New England. What is a key distinguishing factor of fluke compared to most other fish?
a) They can change their color based on the substrate beneath them
b) They exhibit asymmetrical metamorphosis
c) They have the lowest rates of scromboid reaction of any fish known to humans
d) Their meat smells like apricots when raw
e) When cooked in a lemon butter sauce, they pair well with a Chilean Carménère
Two Right Answers!
a) They can change their color based on the substrate beneath them
b) They exhibit asymmetrical metamorphosis
Asymmetrical metamorphosis means that they hatch and lives their early life as a normal appearing fish, but over time their eyes migrate to the same side of their head, now with a flat body, which allows them to ambush prey on the sea floor
While Carménère is my favorite wine, as a bold, spicy, deep red South American wine, it does not pair well with a mild whitefish in a lemon butter sauce