1. Bronchiolitis
90% due to RSV: wheezing, retractions, rales; apnea if <3 months
Tx: trial of beta-agonist, racemic epinephrine
Steroids generally not considered useful
Kids

2. Pneumonia
Neonate: group B streptococcus, E. coli, H. influenzae B
Young child: Streptococcus pneumoniae, H. flu
Kids

3. Pertussis
Prodrome 1 – 2 weeks: mild cough, conjunctivitis, coryza
Then: severe cough, post-tussive emesis, dehydration, subconjunctival hemorrhage, petechiae
“Whooping Cough”
Tx: erythromycin
Kids

4. 17.0 Toxicology

5. Know Your Toxidromes! Opiods
CNS + pupils (miosis) + respirations ± HR
Opioids
Tx: ventilate, naloxone
Opiods

6. Sympathomimetics Uppers
Agitation, mydriasis (pupils), diaphoresis, HR, T, BP, rhabdomyolysis, seizures, myocardial ischemia
Cocaine, amphetamines
Tx: cooling, sedation (BZDs)
Consider phentolamine
Uppers

7. Cholinergic
Salivation, lacrimation, diaphoresis, N/V, fasciculations, bronchorrhea, bradycardia
Insecticides
Tx: atropine, pralidoxime
SLUDGE

8. Anticholinergic Mad Dry
Altered mental status, T, mydriasis, dry flushed skin, urinary retention, seizures, rhabdomyolysis
Atropine, jimsonweed
Tx: sedation, cooling; physostigmine
Mad Dry
Red Hot

9. Salicylates
Altered mental status, tachypnea, HR, diaphoresis, tinnitus, T, anion gap metabolic acidosis
ASA, oil of wintergreen
Tx: multi-dose activated charcoal, alkalinize urine, hemodialysis
A S A

10. Serotonin
Altered mental status, muscle tone, reflexes, T, “wet dog shakes”
Meperidine / dextromethorphan + MAOI or SSRI
SSRI + TCA
SSRI/TCA/MAOI + amphetamine
Tx: cool, sedate, cyproheptadine
S S R I

11. EKG Pearl Tachycardic EKG + drug overdose = digoxin or tricyclic
TCA: large S in I, large R in aVR, wide QRS, long QT
Digoxin: PAT with block, regular atrial fibrillation, high-grade atrioventricular block
Pearl

12. Digoxin
EKG

13. Digoxin
EKG

14. Tricyclic Antidepressant
EKG

15. Tricyclic Antidepressant
 NaHCO3 indications:
QRS 100 msec
R in aVR 3 mm
Ventricular dysrhythmias
Hypotension
New RBBB
No flumazenil, physostigmine
T C A

16. Activated Charcoal MDAC Does not absorb: Lithium Alkali / acid Iron
Heavy metals
MDAC

17. Possible Dialysis for…
Isopropyl alcohol
Salicylates
Theophylline
Uremia
Methanol
Barbiturates
Lithium
Ethylene glycol
Dialysis
I STUMBLE

18. Whole Bowel Irrigation
Sustained release, stuffers
Lithium
Iron
Metals (heavy)
W B I
S L I M

19. Acetaminophen
APAP = Paracetamol = Tylenol® = Ultracet® = Percocet® = Darvocet® = Fioricet ® etc.
140 mg/kg: toxic ingestion
140 mg/kg: loading dose of NAC
140 mcg/ml: 4-hour toxic level
1 4 0

20. Antidotes! Antidote APAP: N-acetylcysteine Arsenic: BAL chelation
Lead: BAL or EDTA chelation
Cyanide: amyl nitrite pearl  sodium nitrite  sodium thiosulfate
Antidote

21. Antidotes! Antidote Methanol: fomepizole (Antizol®) or ethanol, folate
Ethylene glycol: fomepizole (Antizol®) or ethanol, calcium
Iron: deferoxamine
Organophosphates: atropine, pralidoxime (2PAM)
Antidote

22. Antidotes!
INH causes intractable seizures + metabolic acidosis: pyridoxine (vitamin B6)
Digoxin: Fab fragments
Carbamazepine: causes hyperammonemia, give carnitine
Antidote

23. Antidotes! Antidote Carbon monoxide: high-flow O2, hyperbaric oxygen
Calcium-channel blocker: calcium, glucagon
Beta-blockers: glucagon
Antidote

24. Ethylene Glycol Ethylene Glycol Presentation: AMS, drunk
CHF, hypotension
Renal failure
Lab
Calcium oxalate crystals in urine
Urine flouresces with Wood’s lamp
Anion gap, osmolar gap, acidosis
Hypocalcemia may be severe
Ethylene Glycol

25. Methanol Methanol Presentation: AMS, drunk Visual disturbance
Abdominal pain
Physical exam:
Retinal edema, optic disc hyperemia
Methanol

26. Methanol Methanol Lab: Anion gap, osmolar gap, acidosis
Toxicity from formaldehyde and formic acid.
 folate: converts formic acid to CO2
Methanol

27. Alkalinize… Alkalinize …serum for TCAs
…urine for salicylates, barbiturates, chlorpropamide
Alkalinize

28. 18.0 Trauma

29. Head Injury Head Epidural: middle meningeal art.
Subdural: venous bleeding
Head

30. Penetrating
Neck

31. Fractures
Hangman’s fracture
Extension and distraction
Neck

32. Ligament Rupture Neck Extremely unstable Note STS Predental space
Less than 3 mm
Neck

33. Pseudosubluxation Neck
Swischuk line: passes through or within 1.5 mm of arch of C2
Neck

34. Jefferson Fracture
C1 burst: axial load
Neck

35. Wedge or Compression
Loss of >50% height: unstable
Neck

36. Hemothorax Chest See on upright chest x-ray with 200 – 300 cc of blood
Large chest tube (34 – 40 F)
Auto-transfusion if available
Thoracotomy for:
Unstable vital signs
>300 – 400 cc/hr for 4 hours
>1500 cc in 12 to 24 hours
Chest

37. Aortic Rupture
Most common location: between ligamentum arteriosum and left subclavian artery
Chest

38. Aortic Rupture Chest High level of suspicion X-ray findings (many)
Widened mediastinum
Esophageal deviation to right
Chest

39. Diaphragm Rupture Chest
Most common: from penetrating injury, blunt only 4-5%
Doubles with pelvic fracture
Left > right
Liver is protective
Can be very subtle
Up to 50% not diagnosed till surgery
Chest

40. DPL Belly Blunt trauma: Gross blood aspirated >100,000 RBCs / mm3
>500 WBCs / mm3
Amylase > 200 units/ml
Bile, vegetable material or bacteria
Penetrating trauma: fewer cells
Belly

41. Lap Belt Injury Belly Duodenal hematoma Bowel perforation
Chance fracture: spinous process, pedicles, vertebral body
Belly

42. FAST
Belly

43. Trauma in Pregnancy Pregnancy Primary survey unchanged
Secondary survey:
Fundal height
Uterine irritability
Fetal heart tones
Most common cause of traumatic fetal death: abruptio placentae
Pregnancy

44. Scaphoid Fracture
Most commonly fractured carpal bone
Bones

45. Carpal Dislocations
Bones

46. Italians of the Forearm…
GRUM
Galeazzi
Monteggia

47. Galeazzi
Galeazzi = Radius
GRUM

48. Monteggia
GRUM
Ulna = Monteggia

49. Fat Pads
Bones

50. Fat Pads Bones Small anterior: may be normal
Sail sign: large anterior fat pad
Posterior: always pathologic
Suggest elbow fracture
Adults: radial head fracture
Pediatrics: supracondylar fracture
Bones

51. Posterior Shoulder Bones Fall, seizure, electric shock “Lightbulb”
sign

52. Jones Fracture Bones Transverse neck 5th metatarsal
Orthopedic consultation
Bones

53. Lisfranc Bones Most common midfoot fracture
Disrupted tarsal-metatarsal joint
Fracture base 2nd metatarsal: pathognomonic
Bones

54. Radial Head Subluxation
“Nursemaid’s elbow,” annular ligament pulled from radial head due to distraction
Kids

55. Legg-Calve-Perthes Kids
Avascular necrosis of femoral head; prepubertal, boys > girls
Kids

56. SCFE
Slipped Capital Femoral Epiphysis: boys > girls, obesity, puberty
Kids

57. Pediatrics

58. SIDS / Apnea Kids Sudden Infant Death
Leading cause of death 1 month to 1 year
30 – 50% with URI
Especially RSV
 risk with prone sleep
Kids

59. Resuscitation Kids Intubation ET tube size Straight blade
Uncuffed tube under 8 years
ET tube size
Little finger
Nostril diameter
(16 + age in years) / 4
Kids

60. Resuscitation
Most common cause of cardiac arrest: respiratory arrest
Shock: earliest sign tachycardia, hypotension late
Fluid: crystalloid 20 cc/kg
Kids

61. Resuscitation Kids Epinephrine Atropine: 0.02 mg/kg
0.01 mg/kg 1:10,000 soln. IV/IO
0.1 mg/kg 1:1000 soln. ETT
Atropine: 0.02 mg/kg
Minimum 0.1 mg, maximum 0.5 mg
Kids

62. Resuscitation Kids Supraventricular tachycardia
Infant heart rate >220 / min.
Child >180 / min.
Stable: adenosine 0.1 mg/kg
Unstable: cardiovert 0.5 – 1 J/Kg
Kids

63. Resuscitation Kids V-tach
Lidocaine 1 mg/kg IV
Synchronized cardioversion 0.5 to 1 J/kg
Bradycardia: usually poor ventilation and oxygenation
Asystole: CPR + epinephrine
Kids

64. Questions or comments: contact amalmattu@comcast.net
Good Luck!!
Questions or comments: contact