Digitialis
-for rx svt's and chf
-in foxglove, oleander, lily of the valley
-poisons na-k atpase pump -> inc sarco ca + inc extracell K -> inc vagal tone and dec cond AV node
si/sx
-acute od - n/v, bradydys, svt dys with av block, vent dys
-chronic tox - elderly on diuretics; GI sx, weakness, yellow-green halos, syncope, ams, hallucinations, szs, vent dys
-inc risk incl elderly, copd, ht, renal dis, hypokal
labs:
-therapeutic dig level is .5 to 2.0 ng/ml; levels most reliable 6 hr p ingest; chronic tox levels may be low-norm
-lytes for k level
Rx
-vitals, o2, monitor, iv
-act charcoal 1g/kg then .5 g/kg q 4-6h
-bradydys - atropine .5-2.0 mg iv/pacing
-vent dys - phenytoin 15mg/kg iv, no faster than 25 mg/min infusion; lidocaine 1mg/kg iv; mgso4 2-4g iv; cardioversion 10-25 w/s for refractory vent dys (last resort)
-hyperkal - glc + insulin, bicarb, resin, HD; avoid calcium chloride
-dig-specific Fab - indications vent dys, bradydys w/hypotn, hyperkalemia >5.5
Dispo
-asx after 12 hrs of obs
-given fab - icu setting
Tuesday, August 7, 2007
Tox: Calcium Channel Blocker OD
-verapamil is most potent, causes more deaths than all others combined
-sust release and sec gen dihyropyridines (nifedipine) extend duration of clinical tox -> delay in clinical manifestation
si/sx
-sinus bradycard with hypoten, cond disturb, complete sinus arrest with vent escape rhythms
-dec brain perf - dizziness, lethargy, agitation, conf, sz, hemiplegia
-gen weakness, metabolic acidosis with hyperglycemia, noncard pulm edema, hypo/hyperkalemia, hypercalcemia
-severe - slow jxnal rhythm, hypoxemia, lactic acidosis, dec lvef on echo
labs
-abg, lytes
Rx
-vitals, o2, monitor, iv
-activated charcoal 1g/kg
-whole-bowel irrigation for sust release preps
-hypoten
1) iv fluids then
2) calcium chloride 1g in 100cc ns through central line over 5 min, followed by 20-50mg/kg/h then
3) glucagon .1mg/kg mixed in NS, followed by infusion .1mg/kg/h
4) dopamine 1-20 mic/kg/h
5) amrinone 750 mic/kg IV then infusion 1-20 mic/kg/h
6) insulin 1.0 u/kg over 1 hr then .5 u/kg/h with admin of 20-30 g/h glc
7) 4-aminopyridine 10-50 mic/kg/h
8) cardiac pacing 45-50 beats per min
-acidosis maintain ph>7.20 with hypervent or bicarb
Dispo
-trivial ingestion, asx, nl vitals obs 6hr then clear; if sust release prep, longer
-sust release and sec gen dihyropyridines (nifedipine) extend duration of clinical tox -> delay in clinical manifestation
si/sx
-sinus bradycard with hypoten, cond disturb, complete sinus arrest with vent escape rhythms
-dec brain perf - dizziness, lethargy, agitation, conf, sz, hemiplegia
-gen weakness, metabolic acidosis with hyperglycemia, noncard pulm edema, hypo/hyperkalemia, hypercalcemia
-severe - slow jxnal rhythm, hypoxemia, lactic acidosis, dec lvef on echo
labs
-abg, lytes
Rx
-vitals, o2, monitor, iv
-activated charcoal 1g/kg
-whole-bowel irrigation for sust release preps
-hypoten
1) iv fluids then
2) calcium chloride 1g in 100cc ns through central line over 5 min, followed by 20-50mg/kg/h then
3) glucagon .1mg/kg mixed in NS, followed by infusion .1mg/kg/h
4) dopamine 1-20 mic/kg/h
5) amrinone 750 mic/kg IV then infusion 1-20 mic/kg/h
6) insulin 1.0 u/kg over 1 hr then .5 u/kg/h with admin of 20-30 g/h glc
7) 4-aminopyridine 10-50 mic/kg/h
8) cardiac pacing 45-50 beats per min
-acidosis maintain ph>7.20 with hypervent or bicarb
Dispo
-trivial ingestion, asx, nl vitals obs 6hr then clear; if sust release prep, longer
Tox: Beta Blocker OD
T car Beta Blockers
si/sx
-bradycardia, hypotn, chf, ams, sz
-EKG - QRS widening (propranolol), sotalol may cause QT prolong, vtach, torsades, vfib
Rx:
-vitals, O2, monitor, IV access, EKG
-labs-lytes, bun, cr, glc, abg (acid-base)
-gastric lavage if <1-2hr
-activated charcoal 1g/kg
0) NS bolus 20cc/kg; if bp<90 then
1) glucagon 50 mic/kg IV bolus (.05mic/kg), repeat as necessary
-if any inc in bp after bolus, do infusion at 75mic/kg/h, if bp<90 after 5 min, inc to 150mic
-no change in bp after 5 min from initial bolus, give 100mic/kg bolus, wait 5 min
-don't mix glucagon in the supplied diluent (phenol-sz, hypotn, dysrhyth)), use ns
2) dopamine 5mic/kg/min if <90 inc by 5mic/kg/min q 5min up to 20
3) norepi .5mic/min, inc .5mic/min q5min up to 4.0mic/min
-give 5min for each change in rx to work
-For sotalol, give lidocaine, mgso4, isoproterenol and overdrive pacing for dysrhythmias
Dispo:
-sx can be delayed to 10 hr
-if asx after 8-10h with normal repeat EKG, may be cleared
si/sx
-bradycardia, hypotn, chf, ams, sz
-EKG - QRS widening (propranolol), sotalol may cause QT prolong, vtach, torsades, vfib
Rx:
-vitals, O2, monitor, IV access, EKG
-labs-lytes, bun, cr, glc, abg (acid-base)
-gastric lavage if <1-2hr
-activated charcoal 1g/kg
0) NS bolus 20cc/kg; if bp<90 then
1) glucagon 50 mic/kg IV bolus (.05mic/kg), repeat as necessary
-if any inc in bp after bolus, do infusion at 75mic/kg/h, if bp<90 after 5 min, inc to 150mic
-no change in bp after 5 min from initial bolus, give 100mic/kg bolus, wait 5 min
-don't mix glucagon in the supplied diluent (phenol-sz, hypotn, dysrhyth)), use ns
2) dopamine 5mic/kg/min if <90 inc by 5mic/kg/min q 5min up to 20
3) norepi .5mic/min, inc .5mic/min q5min up to 4.0mic/min
-give 5min for each change in rx to work
-For sotalol, give lidocaine, mgso4, isoproterenol and overdrive pacing for dysrhythmias
Dispo:
-sx can be delayed to 10 hr
-if asx after 8-10h with normal repeat EKG, may be cleared
Hem/Onc: Hemolytic Uremic Syndrome
-occurs <5yo following a URI or gastroenteritis (E coli 157:h7, shigella, salmonella)
fATRn - nephropathy, microangiopathic hemolytic anemia, thrombocytopenia
-GI - 75% have pain (can have intussuseption, perf), vomiting, diarrhea (may be bloody)
-Renal - dec uop (gross hemat rare)
-skin - pallor, petechiae, purpura
-Hypertn in 50%
-CNS - sz, coma, encephalopathy
Lab:
-u/a - hematuria, proteinuria, casts
-CBC - low Hb, low PLT, low WBC
-smear - schistocytes, helmet cells
-low Na & CO2, high K, BUN & Cr
-coags nl
Rx:
-dialysis - CHF, BUN>100, encephalopathy, anuria>24hrs or hyperkalemia
-anti-HTNs
-PRBCs - if hb<8
-plasma exchange - cns or severe renal involvement
-plasmapheresis - as above
-DO NOT give platelets - can worsen organ damage
fATRn - nephropathy, microangiopathic hemolytic anemia, thrombocytopenia
-GI - 75% have pain (can have intussuseption, perf), vomiting, diarrhea (may be bloody)
-Renal - dec uop (gross hemat rare)
-skin - pallor, petechiae, purpura
-Hypertn in 50%
-CNS - sz, coma, encephalopathy
Lab:
-u/a - hematuria, proteinuria, casts
-CBC - low Hb, low PLT, low WBC
-smear - schistocytes, helmet cells
-low Na & CO2, high K, BUN & Cr
-coags nl
Rx:
-dialysis - CHF, BUN>100, encephalopathy, anuria>24hrs or hyperkalemia
-anti-HTNs
-PRBCs - if hb<8
-plasma exchange - cns or severe renal involvement
-plasmapheresis - as above
-DO NOT give platelets - can worsen organ damage
Peds: Henoch-Schonlein Purpura
HSP
-peaks 4-5 yrs old, may occur at any age; winter and early spring
-strep, mycoplasma, hep b, antibx, food antigens, salicylates
-skin - involved in most; petechiae form purpura, gravity dependent buttocks and legs
-painless edema of dorsum of hands and feet, painful of scalp and face
-GI - 50-90% with vomiting or bleeding; intuss, pancreatitis, or bowel infarcts
-joints - 50-75% transitory non-migratory, periarticular swelling, knees, ankles
-renal - 50% may be permanent, gross hematuria 30-40%
Rx:
-steroids for abd pain and renal involvement
-peaks 4-5 yrs old, may occur at any age; winter and early spring
-strep, mycoplasma, hep b, antibx, food antigens, salicylates
-skin - involved in most; petechiae form purpura, gravity dependent buttocks and legs
-painless edema of dorsum of hands and feet, painful of scalp and face
-GI - 50-90% with vomiting or bleeding; intuss, pancreatitis, or bowel infarcts
-joints - 50-75% transitory non-migratory, periarticular swelling, knees, ankles
-renal - 50% may be permanent, gross hematuria 30-40%
Rx:
-steroids for abd pain and renal involvement
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