1. In-Training Exam High Yield Topics Toxicology
ITE High Yield Topics Presentations:
This is one of multiple presentations included in our revised 2018 EMF ITE resources. Presentation content is divided by system and includes the highest-yield (highest % on the test) systems: Cardiovascular, Trauma, Gastrointestinal, Pediatrics, Pulmonary, Toxicology, ID and Neurology. Each system presentation has three different sections: Visual Diagnosis, Clinical Concepts and Rapid Fire. Scattered throughout are “Knowledge Bomb” slides that provide a more in-depth summary of certain high-yield topics.
Timing:
Each presentation in this series is of variable length, thus the time required to lead instruction will also be variable. In general, the expected time range for presentations is minutes. The specific time you’ll need will depend not only on presentation length, but also how much embedded conversation or focused review (“knowledge bomb” content) you intend, in addition to the familiarity of your residents with this content.
Emergency Medicine
Foundations Curriculum

2. In-training Exam (ITE) Content:
Written to level of EM3
Predicts performance on EM Boards
225 MC questions
Given 4.5 hrs to take
+/- 25 are visual stimuli – pictures/ekg/xrays
Highest yield topics
Cardiovascular ~ 10%
Trauma ~ 10%
Abd/GI ~ 8%
Thoracic/Respiratory ~ 8%
Procedures/Skills ~8%
Note that Geriatrics makes up at least 6% of these and Pediatrics at least 8%

3. Foundations Challenge Overview
Rapid Review of High-Yield Test Topics
Visual Diagnosis
Clinical Concepts
Rapid Fire
Work in 2-4 different teams
Answer challenge questions for points
Point value per challenge varies by difficulty
Win test prep and pride
Running the Meeting:
Start by dividing learners into 2-4 teams and direct them to separate areas of the room
You should assign a learner or instructor to serve as scorekeeper and ask for updates on the score when you switch topics
Provide and guide reasonable time limits to answer challenge questions
Monitor time closely as you move through the review to keep pace with planned content
If you have the time/energy, you may consider giving a prize/reward for the winning team

4. Foundations Challenge Rules
Create a Team Name
Best Team Name starts the Challenge
(as arbitrarily determined by your Instructor)
Your team must answer the entire question correctly to win points
If you team answers incorrectly, the Challenge Question points can be stolen by the next team
If they answer correctly, they get your points AND a chance to answer the next question
If they answer incorrectly, the turn passes again to the next team in line
You may choose to modify the point assignment system (all or nothing vs partial credit)

5. toxicology

6. 27 yo f non-responsive, barely breathing
Foundations Challenge
Visual Diagnosis
1pt
27 yo f non-responsive, barely breathing
Dx and Tx?

7. 27 yo f non-responsive, barely breathing
Foundations Challenge
Visual Diagnosis
1pt
27 yo f non-responsive, barely breathing
Dx: Opioid Overdose
Tx: Naloxone

8. HIV+ pt on Dapsone with fatigue, O2 sat 85%
Foundations Challenge
Visual Diagnosis
2 pts
HIV+ pt on Dapsone with fatigue, O2 sat 85%
Dx and Tx?

9. HIV+ pt on Dapsone with fatigue, o2 sat 85%
2 pts
Foundations Challenge
Visual Diagnosis
HIV+ pt on Dapsone with fatigue, o2 sat 85%
Dx: Methemoglobinemia
Tx: Methylene blue

10. methemoglobinemia Knowledge Bomb Foundations Challenge
What is it?
Iron in Hgb gets oxidized to Fe3+ from normal Fe2+, causing impaired O2 binding and tissue hypoxia with methemoglobin levels >10%
Causes
Medications (dapsone, topical anesthetics, nitrites/nitrates, antimalarials, Pyridium), environmental (aniline dyes, well water)
Diagnosis
SaO2 ~85% (consistent with MetHgb >10%), “chocolate”-colored arterial blood, central cyanosis
Treatment
Methylene blue (reduces Fe3+ to Fe2+; N.B. avoid in G6PD deficiency, because this will cause hemolysis)

11. 23 yo m with depression, brought in after suicide attempt
2 pts
Foundations Challenge
Visual Diagnosis
23 yo m with depression, brought in after suicide attempt
Dx and Tx?

12. 23 yo m with depression, brought in after suicide attempt
Foundations Challenge
Visual Diagnosis
2 pts
23 yo m with depression, brought in after suicide attempt
Dx: TCA overdose
Tx: sodium bicarb

13. TCA overdose Knowledge Bomb Foundations Challenge TCA overdose
TCA Medications
Amitriptyline, nortriptyline, doxepin
Affects
Basically all neuroreceptors (ACh -> anticholinergic ssx, NE -> alpha blockade, Na channel -> wide QRS, histamine, GABA -> seizures)
Diagnosis
No levels are available; consider for pt with depression, presenting with AMS, seizures, QRS widening, VT/VF
Treatment
Sodium bicarbonate (competes against Na channel blockade -> narrow QRS, decreased risk of VT/VF), otherwise supportive care only

14. How can you differentiate these toxidromes?
Foundations Challenge
Clinical Concepts
2 pts
How can you differentiate these toxidromes?
Serotonin syndrome
Neuroleptic malignant syndrome

15. How can you differentiate these toxidromes?
Foundations Challenge
Clinical Concepts
2 pts
How can you differentiate these toxidromes?
Serotonin syndrome
Neuroleptic malignant syndrome
Both will be hyperthermic, likely agitated
Clonus/hyperreflexia
Muscle rigidity

16. How can you differentiate these toxidromes?
Foundations Challenge
Clinical Concepts
2 pts
How can you differentiate these toxidromes?
Anticholinergic
Sympathomimetic

17. How can you differentiate these toxidromes?
2 pts
Foundations Challenge
Clinical Concepts
How can you differentiate these toxidromes?
Anticholinergic
Sympathomimetic
Both will be hyperthermic, although to a low degree, and both will likely be agitated (although anticholinergic toxidromes can also be obtunded or lethargic).
Anticholinergic toxidrome:
“Dry as a bone, hot as a hare, mad as a hatter, blind as a bat, red as a beet”
Sympathomimetic toxidrome:
Everything gets ramped up, causing a “fight or flight” physiologic response with mydriasis, tachycardia, agitation, and diaphoresis
Dry (“as a bone”)
Sweaty

18. Hot Tox (hyperthermic)
toxidromes
Foundations Challenge
Knowledge Bomb
Hot Tox (hyperthermic)
Agitated
Sedated
Sympathomimetic (sweaty)
PCP/cocaine (superhuman strength)
Opioid
(miosis)
Anticholinergic
(dry)
Withdrawal syndromes
(esp. EtOH)
EtOH/benzos
(no miosis)
NMS
(muscle rigidity)
Cholinergic
(wet, DUMBBELSS)
Serotonin syndrome
(clonus)
Malignant hyperthermia
(got succinylcholine)

19. When is activated charcoal contraindicated?
Foundations Challenge
Clinical Concepts
2 pts
When is activated charcoal contraindicated?
Name 1
When is activated charcoal ineffective?
Name 1

20. When is activated charcoal contraindicated?
2 pts
Foundations Challenge
Clinical Concepts
When is activated charcoal contraindicated?
AMS/obtunded, Ileus,
Vomiting, Risk of Seizure
When is activated charcoal ineffective?
Metals, Alcohols, Hydrocarbons, Caustics

21. Foundations Challenge
Clinical Concepts
2 pts
What is the classic metabolic disorder with salicylate toxicity? When do you dialyze for salicylate toxicity?

22. 2 pts
Foundations Challenge
Clinical Concepts
What is the classic metabolic disorder with salicylate toxicity? When do you dialyze for salicylate toxicity?
Concurrent metabolic acidosis and respiratory alkalosis
Acute: ASA>100mg/dL Chronic: ASA>60mg/dL OR
Presence of renal failure, severe acidemia, cerebral/pulmonary edema

23. 3 pts Associations Garlic smell, multi-organ failure
Foundations Challenge
RAPID FIRE
3 pts
Associations
Garlic smell, multi-organ failure
Rotten eggs smell, unconscious pt
On meds for TB, p/w seizure
???

24. 3 pts Associations Garlic smell, multi-organ failure
Foundations Challenge
RAPID FIRE
3 pts
Associations
Garlic smell, multi-organ failure
Rotten eggs smell, unconscious pt
On meds for TB, p/w seizure
Arsenic
Hydrogen sulfide
Isoniazid

25. 2 pts Antidote time! Cyanide Methemoglobinemia ??? RAPID FIRE
Foundations Challenge
RAPID FIRE
2 pts
Antidote time!
Cyanide
Methemoglobinemia
???

26. 2 pts Antidote time! Cyanide Hydroxycobalamin OR
Foundations Challenge
RAPID FIRE
2 pts
Antidote time!
Cyanide
Methemoglobinemia
Hydroxycobalamin OR
Na thiosulfate+Amyl nitrate+Na nitrate
Methylene blue

27. 3 pts Antidote time! Acetaminophen ??? Benzodiazepines
Foundations Challenge
RAPID FIRE
3 pts
Antidote time!
Acetaminophen
Benzodiazepines
Methanol/Ethylene Glycol
???

28. 3 pts Antidote time! Acetaminophen N-acetylcysteine (NAC)
Foundations Challenge
RAPID FIRE
3 pts
Antidote time!
Acetaminophen
Benzodiazepines
Methanol/Ethylene Glycol
N-acetylcysteine (NAC)
Flumazenil (NB: may cause seizure)
EtOH or fomepizole

29. Antidote time: toxidromes
Foundations Challenge
RAPID FIRE
5 pts
Antidote time: toxidromes
Sympathomimetic
Anticholinergic
Serotonin syndrome
Neuroleptic malignant syndrome
Malignant hyperthermia
???

30. Antidote time: toxidromes
Foundations Challenge
RAPID FIRE
5 pts
Antidote time: toxidromes
Sympathomimetic
Anticholinergic
Serotonin syndrome
Neuroleptic malignant syndrome
Malignant hyperthermia
Benzos
Benzos, consider physostigmine
Benzos, consider cyproheptadine
Benzos, consider bromocriptine
Dantrolene

31. 5 pts Antidote time: Metals Iron ??? Lead Mercury Arsenic Lithium
Foundations Challenge
RAPID FIRE
5 pts
Antidote time: Metals
Iron
Lead
Mercury
Arsenic
Lithium
???

32. 5 pts Antidote time: Metals Iron Deferoxamine Lead Dimercaprol or EDTA
Foundations Challenge
RAPID FIRE
5 pts
Antidote time: Metals
Iron
Lead
Mercury
Arsenic
Lithium
Deferoxamine
Dimercaprol or EDTA
Dimercaprol
Hemodialysis

33. Good Luck!!!

34. References Foundations Teaching Content: References:
Dr. Andrew Ketterer, MD, MA
Medical Education Fellow, Beth Israel Deaconess
Dr. Kristen Grabow Moore, MD, MEd
Assistant Professor, Emory University
References:
Life in the Fast Lane
HippoEM Board Review
Rivers Written Board Review
Medscape emedicine
Northwestern EM Chief Residents
Author: Dr. Andrew Ketterer, Beth Israel Deaconess Medical Center
Editor: Dr. Kristen Grabow Moore, Emory University
Content Revision 01 / 2018
References:
Life in the Fast Lane
HippoEM Board Review
Rivers Written Board Review
Medscape emedicine
Northwestern EM Chief Residents