Osmolality

Normal <10

Elevatedlevel(1000 pmotL 4 h after

Acetaminophen ingestion)

Consult RumackMatthew nomogram in

single ingestion cases

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D3 - Decontamination and Enhanced Elimination

Ocular Decontamination

• saline irrigation to neutralize pH;alkali exposure requires ophthalmology consult

Dermal Decontamination

• wear protective gear

• remove clothing, brush ofTtoxic agents, irrigate all external surfaces

Gastrointestinal Decontamination

• single dose activated charcoal

use of activated charcoal is a source of much debate amongst toxicologists,evidence of

effectiveness is not strong and risk of aspiration is high

consider if recent ingestion, delayed absorption medication,can consult poison control PRN

adsorption of drug/toxin to activated charcoal decreases toxin bioavailability

contraindications: unprotected airway, late presentation after ingestion (1-2 h post ingestion),

small bowel obstruction, poor toxin adsorption

dose: 10 g/g drug ingested or lg/kgbody weight (may vary depending on ingestion)

odourless, tasteless, prepared asslurry with H:0

• whole bowel irrigation (occasionally used)

500 mL/h (child) to 2000 mL/h (adult) of polyethylene glycol solution by mouth until clear

effluent per rectum

start slow (500 mL in an adult) and aim to increase rate hourly as tolerated

indications

awake, alert, can be nursed upright, with an NG tube who cannot tolerate drinking it,or

intubated and airway protected

delayed release product

drug/toxin not bound to charcoal

drug packages (if any evidence of breakage emergency surgery)

recent toxin ingestion

• contraindications

evidence of ileus, perforation, or obstruction

• multidose activated charcoal

• may be used for: carbamazepine, phenobarbital,quinine, theophylline,for toxins which undergo

enterohepatic recirculation

removes drug that has already been absorbed by drawing it back intoG1 tract

various regimens:12.5g (1/4bottle) PO ql h or 25g (1/2 bottle) PO q2 h until non-toxic

• surgical removal in extreme cases

surgical indicated for drugs that are toxic,form concretions,or cannot be removed by

conventional means

• use of cathartics(i.e. ipecac) and gastric lavage in the ED is generally not recommended

Lipid Emulsification

• new therapy used in cardiogenic shock due to toxins

• may be used for: anesthetics (e.g. lidocaine), (5-blocker/calcium channel blocker, atypical

antidepressant overdose

• initial bolus lipid solution 20% 1.5 mL/kg over 3 min then infusion of 0.25 mL/kg/min

Urine Alkalinization

• may be used for:ASA, methotrexate, phenobarbital, chlorpropamide

• weakly acidic substances can be trapped in alkaline urine (pH >7.5) to increase elimination

Hemodialysis

• indications/criteria for hemodialysis

toxins that have high water solubility, low protein binding, low molecular weight,adequate

concentration gradient,small volume of distribution,or rapid plasma equilibration

clinical deterioration despite maximal medical support

• useful for the following toxins

methanol

ethyleneglycol

salicylates

lithium

phenobarbital

chloral hydrate (trichloroethanol)

• others include theophylline, carbamazepine, valproate,methotrexate

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ER52Emergency Medicine Toronto Notes 2023

E - Expose and Examine the Patient

• vital signs (including temperature), skin ( needle tracks,colour), mucous membranes, pupils, odours,

and CNS

• head-to-toe survey including

C-spine

signs of trauma,seizures (incontinence, “tongue biting,

" etc.), infection (meningismus),or

chronic alcohol/drug misuse (track marks, nasal septum erosion)

• feel the patient’s axillae;in the average patient,should be somewhat moist (if dry,may indicate

anticholinergic toxicity)

• mental status

Table 32, Specific Toxidromes

Overdose Signs and Symptoms

Hyperthermia

Dilated pupils

Dry skin

Vasodilation

Agitalion/hallucinalions

Ileus

Urinary retention

Tachycardia

-DUMBELS*

Diaphoresis.Diarrhea, Decreased BP

Urination

Miosis

Bronchospasm. Bronchorihca. Bradycardia

Emesis. Excitation of skeletal muscle

Lacrimation

Salivation, Seizures

Dysphonia.dysphagia

Rigidity and tremor

Motor restlessness, crawling sensation (akathisia)

Constant movements (dyskinesia)

Dystonia (muscle spasms, laiyngospasm. trismus,

oculogyric crisis, torticollis)

Increased respiratory rate

Decreased LOC

Seizures

Cyanosis unresponsive to Or

lactic acidosis

Toxidrome Examples of Drugs

Anticholinergic “Hot as a hare”

"Blind as a bat"

"Dry as a bone"

“Red as a beet"

“Mad as a hatter"

Antidepressants (e.g . ICAs)

Cyclobeniaprine ( Flcxeril '

)

Carbamate pine

Antihistamines (e.g.diphenhydramine)

Antiparkinsonians

“The bowel and bladder lose Antipsychotics

their tone and the heart goes Antispasmodics

on alone” Belladonna alkaloids (e.g.atropine)

Cholinergic Natural plants: mushrooms,trumpetflower

Anticholinesterases: physostigmine

Insecticides (organophosphates.carbamates)

Nerve gases

Extrapyramidal Ma|or tranquilizers

Antipsychotics

Hemoglobin

Derangements

CO poisoning (carboxyhemoglobin)

Drug ingestion (methemoglobin.sulfmethemoglobin)

Opioid,Sedative/

Hypnotic, EIOH

Hypothermia

Hypotension

Respiratory depression (opioid)

Dilated or constricted pupils (pinpoint in opioid)

CHS depression

Increased temperature

CNS excitation (including seicures)

Tachycardia. H1N

EIOH

Benzodiazepines

Opioids (morphine, heroin,fentanyl. etc.)

Barbiturates

CHS ("G." "liquid gold")

Amphetamines, caffeine, cocaine.ISO. phencyclidine

Ephedrinc and other decongestants

Thyroid hormone

Sedative or EIOH withdrawal

Sympathomimetic

N /Y

Diaphoresis

Dilated pupils

Serotonin Syndrome Mentalstatus changes, autonomic hyperactivity,

neuromuscular hyperactivity, hyperthermia,diarrhea. HTN

MAOI.TCA.SSRI, opiate analgesics

Cough medicine,weight reduction medications

Note:ASA poisoning end hypoglycemia mimic sympathomimetic toxidrome

F - Full Vitals, ECG Monitor, Foley, X-Rays

G - Give Specific Antidotes and Treatments

Urine Alkalinization Treatment for ASA Overdose

• urine pH >7.5

• fluid resuscitate first, then 3 amps NaHCOi/L of D5\V at 1.5.x maintenance

• add 20-40 mEq/L KC1 if patient is able to urinate r t

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Table 33. Protocol for Warfarin Overdose

Management:Consider Prothrombin CompelConcentrate (Octaplex:

.Beriplex:

) tor any elevated INR.AND either life-threatening

bleeding,or a plan for the pabent to undergo a surgical procedure within the next 6 h (vitamin K takes 4-6 h post IV administration

to work)

Cessation of warfarin administrate!!.obsenrabon.serial INR PI

INR

<5.0

5.1-9.0 If no risk factors for bleeding,hold warfarin x1-2d and reduce maintenance dose

OR Vitamin K1-2mgP0if patient at increased risk of bleeding

9.1-20.0 Hold warfarin,vitamin K 2-4mgPO.serial INRPT.addibonal vitamin K if necessary

>20.0 Hold warfarin,vitam nit10 mg IV over 10 --. ncrease vitar - Kdssng (g4 h) f -eeded

Table 34. Specific Antidotes and Treatments for Common Toxins*

Toxin Treatment Considerations

Often clinically silent:evidence of liver/renal damage delayed >24 h

fete dose >200 mg'kg (»7.5 g adult)

Monitor drug level 4 h post-ingestion;also liver enzymes, INR,

PIT.SUN.Cr

Hypoglycemia,metabolic acidosis,encephalopathy poor prognosis

0;alysis may berequired tomanage in very high overdoses

Berutropme (Cogentm |has euphoric effect and the potential for

misuse

Acetaminophen Decontaminate(activated charcoal)

N-acetylcysteine

Benztropine:12 mg IM IV then 2 mgP03 d

OR Oiphenhydramine12 mg/kgIV.then 25mgP0

010 x3 d

Consider decontammabon (activated charcoal)

Supportive care

Consider decontaminabon (activated charcoal)

Alkalinize urine:want urine pH >7.5

Acute Dystonic

Reaction

Anticholinergics Special anbdotes available:consult Poison Information Centre

ASA Monitor serum pH and drug levels closely

Monitor Ktevel:may require supplement for urine alkalinization

Hemodialysis may be needed if intractable metabolic acidosis,

very high levels,or end-organ damage (i.e. unable to diurese)

Benzodiazepines Consider decontamination (activated charcoal)

Flumazeml (onlyuse in iatrogenic overdose (operative

oversedabon) due to extensive contramdications

(mixedoverdose.Hx of EtOH.seizures))

Supportive care

Consider decontamination (activated charcoal,consider

whole bowelirrigation for extended-release ingestion)

IV glucagon.IV calcium chloride.IVhigh-dose insubn

(with dextrose).IVlipid emulsificabon

Consider deconta- nabon (acbvated charcoal,consider Order EC6.electrolytes (especially Ca

*

-.Mg 2\ Ha’.K'

)

whole bowelirrigabon for extended-release ingesbon)

IV glucagon.[V calcium chloride.IVhigh-dose insulin

(with dextrose).IVintralipid

Decontaminate (acbvated charcoal)if oral

Aggressive supportive care

p-blockers

Calcium Channel

Blockers

Cocaine 3-blockers are contraindicated in acute cocaine toxicity

Intralipid for life-threatening symptoms

Consider benzodiazepines for any major side effect of cocaine

overdose (agitation,hypertension,tachycardia,etc.)

Order ECG.VBG.Considerlactate and troponin depending on

specific presentabon

See Inhalation Injury.fl?47

Supportive care

100“

c 0J;may requirehyperbaric 0

’

Hydroxocobalamin Sg IV (Cyanokit'

)

Consider decontaminabon (activated charcoal)

Oigoxm-specific antibody fragments

10- 20 vials IV if acute:3-6 if chronic

1vial (40 mg) neutralizes0.5mg of toxm

Thiamine100 mg IMilV

Manage airway and circulatory support

CO Poisoning

Cyanide

Digoxin

Consider in all patients found in a fire

Use for life-threatening dysrhythmias unresponsive to

conventional therapy.6h serum digoxin >12 nmol/L.initial K- >5

mmol/ .ingestion >10 mg|adult)/>4 mg (child)

Common dysrhythmias include VFib.VTach.and conduction blocks

Mouthwash - 70% EtOH:perfumes and colognes - 40 60% EtOH

Order serum EtOH level and glucose level:treat glucose level

appropriately

CBC.electrolytes,glucose,ethanol level

Consider hemodialysis

Ethanol

Ethylene Glycol/

Methanol

Fomepizole (4-methylpyrazole)

15 mg/kgIV load over 30 mm.

then10 mg,rkgq12 hOR

Ethanol (10%)10 mL Vg over 30min.then 1.5mt/h

Protamine sulfate25-50 mgIV

Glucose IV.PO/NG tube

Glucagon:1-2mgIM(if no access to glucose)

Heparin

InsulinIM/SC/

For unfracbonated heparin overdose only

Glyburide carries highest risk of hypoglycemia among oral agents

Consider ocbeotide for oral hypoglycemics (50-100 pg SC q6 h|in

these cases:consult local Poison Information Centre

Monitor CK:treatrhabdomyolysis with high flow fluids: aggressive

eitemal cooling for hyperthermia

Review medical history if possible for serotonergic use

Oral

Hypoglycemic

MDMA Consider decontaminabon (acbvated charcoal)

Supportive care

Opioids

TCAs

See Universal Antidotes.f.R4i?

Consider decontaminabon (acbvated charcoal)

Aggressive supportive care

NaHCOs bolus for wide ORSseizures

r *>

u J

Flumazeml antidote conbaindicafedin combinedICA and

benzodiazepine overdose

Also consider cardiac andhypotension support,seizure control

Intralipid therapy

Organophosphate 100

Atropine

% 0

’

endotracheal intubation Succinylcholine +

Pralidoxime (2-PAM)

* Call local PoisonInformation Centre for reporting of cases,specif c doses,andtreatment recommendations. Most toxicology cases should involve

communication with your localPoisonInformation Centre

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ER54 Emergency Medicine Toronto Notes 2023

Alcohol Related Emergencies

• see Psychiatry. PS29

ft

Acute Intoxication

• slurred speech,CNS depression,disinhibition, lack of coordination

• nystagmus, diplopia,dysarthria, ataxia, may progress to coma

• hypotension (peripheral vasodilation)

• if obtunded, rule out

head trauma/intracranial hemorrhage

associated depressants, toxic alcohols

• may also contribute to respiratory/cardiac depression

hypoglycemia (screen with bedside glucometer)

• hepatic encephalopathy: confusion, altered LOO, coma

• precipitating factors: Cil bleed, infection,sedation, electrolyte abnormalities, protein meal

• Wernicke’s encephalopathy (ataxia,ophthalmoplegia, delirium)

post-ictal state, basilarstroke

Withdrawal

• beware of withdrawal signs

• treatment

diazepam 10-20 mg I WEI)or lorazepam 2-4 mg 1V/PO q 1 h (if known liver dysfunction) until two

negative CIWA scores

• frequency of dosing may have to be increased depending on clinical response

may use CIWA protocol and give benzodiazepines as above until CIWA <10

thiamine 200 mgIM/IV then 50-100 mg/d

naltrexone & gabapentin if no improvement

magnesium sulfate 4 g 1V over I -2 h (if hypomagnesemic)

admit patients with delirium tremens or multiple seizures or persistently high CIWA (symptoms)

despite high doses of benzodiazepines

Alcohol levels correlate poorly with

intoxication

Alcohol intoxication may invalidate

informed consent

*

CIWA Withdrawal Symptoms

• N/V

• Tremor

• Paroxysmalsweats

• Anxiety

• Agitation

• Visual disturbances

. Tactile disturbances

• Auditory disturbances

• Headache

• Disorientation

• 10 symptoms each scored out of 7

except orientation, which isscored

out of 4

Table 35. Alcohol Withdrawal Signs

Time Since Last Drink Syndrome Description

6-8 h Generalized tremor,anxiety,agitation,but no delirium

Autonomic hyperactivity (sinustachycardia),insomnia,HIV

Visual (most common),auditory,and tactile hallucinations

Vitals often normal

Typically brief generalizedIonic-clonic seizures

May have several withina few hours

Clhead if focal seizures have occurred

5%of untreated withdrawal patients

Severely confused state,fluctuating LOC

Agitation,insomnia,hallucinations/delusions,tremor

Tachycardia,hyperpyrexia, diaphoresis

High mortality rale

Mild withdrawal

1-2 d Alcoholic hallucinations

8 h-2 d Withdrawal seizures

3-5d D1

Cardiovascular Complications

• H1N

• cardiomyopathy:SOB, edema

• dysrhythmias(“holiday heart”)

• Al

-

'

ib (most common), atrial flutter,SVT, VTach (especially Torsades if hypomagnesemic/

hypokalemic)

Metabolic Abnormalities

• alcoholic ketoacidosis

metabolic acidosis, urine ketones, low glucose, and normal osmolality

history of chronic alcohol intake with abrupt decrease/ccssation

malnourished, abdominal pain with N/V

treatment: thiamine (250-500 mg IM/IV prior to dextrose), dextrose, volume repletion (with NS)

• generally resolves in 12-24 h

• toxic alcohols

ethylene glycol:CNS,CVS, renal findings

• methanol

early:lethargy, confusion

late: headache, visual changes, N/V, abdominal pain, tachypnea

toxic alcohols initially produce a high osmolar gap, as the toxic alcohol is metabolized the

osmolar gap drops and an anion gap developsleading to a severe metabolic acidosis, the goal of

treatment is to block this pathway

EtOH co-ingestion is protective

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• treatment

• urgent hemodialysis required

» fomepizole 15 mg/kg IV bolus (treatment of choice) or 10% EtOH IV bolus and infusion to

achieve blood level of 22 mmol/L (EtOH loading may be done PO)

consider folic acid for methanol, and pyridoxine and thiamine for ethylene glycol- both help

reduce conversion to active metabolites

• other abnormalities associated with alcohol:hypomagnesemia, hypophosphatemia, hypocalcemia,

hypoglycemia, hypokalemia

Gastrointestinal Abnormalities

• gastritis

common cause of abdominal pain and Cil bleed in chronic alcohol users

• pancreatitis

serum amylase very unreliable in patients with chronic pancreatitis, may need serum lipase

hemorrhagic form (15%) associated with increased mortality

fluid resuscitation very important

• hepatitis

AST/ALT ratio >2 suggests alcohol as the cause

• peritonitis/spontaneous bacteria] peritonitis

leukocytosis,fever,generalized abdominal pain/tenderness

occasionally accompanies cirrhosis

paracentesisfor diagnosis (common pathogens:t.coli, Klebsiella, Streptococcus)

albumin shown to improve outcomes in sBP patients

• G1 bleeds

most commonly gastritis or ulcers, even if patient known to have varices

consider Mallory-Weiss tear secondary to retching

often complicated by underlying coagulopathies

minor: treat with antacids

• severe or recurrent: endoscopy

variceal bleeds: octreotide

Disposition from the Emergency Department

• alcohol

before patient leaves ED ensure stable vitalsigns, can walk unassisted, and fully oriented

offer social services to find shelter or detox program

ensure patient can obtain any medications prescribed and can complete any necessary follow-up

• methanol, ethylene glycol

delayed onset, admit, and watch clinical and biochemical markers

• T'CAs

• prolonged /delayed cardiotoxicity warrants admission to monitored 1CU bed

• if asymptomatic and no clinical signs of intoxication:6 h ED observation adequate with proper

decontamination and no ECCi abnormalities

• sinus tachycardia alone (most common finding) with history of overdose warrants observation in

ED

• hydrocarbons/smoke inhalation

pneumonitis may lag 6-8 h

consider observation for repeated clinical and radiographic examination

• ASA,acetaminophen

if borderline level,get second level 2-4 h after first

• for ASA, must have at least 2 measurementsshowing decreasing toxin serum concentration

before discharge (3levels minimum)

• oral hypoglyccmics

admit all patients for minimum 24 h if hypoglycemic and 12 h after last octreotide dose

• observe asymptomatic patient for at least 8 h

• opioids

administer naloxone, a short

-acting opioid antagonist, preferably IV in incremental doses (0.2-1

mg)

patients in cardiorespiratory arrest following possible opioid overdose should be given 2 mg of

naloxone minimum

admit and observe for 24h

referral to rapid access clinic and offer a naloxone kit

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Psychiatric Consultation

• once patient medically cleared, arrange psychiatric intervention if required

• beware -suicidal ideation may not be expressed

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Psychiatric Emergencies

Approach to Common Psychiatric Presentations

. see Psychiatry. PS2 $

• before seeing patient,ensure your own safety; have security/police available if necessary

History

• safety

assess suicidality:suicidal ideation (SI; passive/active), intent, plan, lethal means, past attempts,

protective factors

assess homicidality:homicidal ideation (HI), access to weapons, intended victim, and history of

violence

• driving and children

• command hallucinations

• identify current stressors and coping strategies

• mood symptoms: manic, depressive

• anxiety: panic attacks, generalized anxiety, phobias, obsessive-compulsive disorder, post-traumatic

stress disorder

• psychotic symptoms:delusions, hallucinations, disorganized speech, disorgani

behaviour, negative symptoms (affective flattening, alogia, avolition)

• substance use history: most recent use, amount, previous withdrawal reactions

• past psychiatric history, medications, adherence with medications, admissions

• medical history: obtain collateral if available

Physical Exam

• complete physical exam focusing on: vitals, neurological exam,signs of head trauma, signs of drug

toxicity,signs of metabolic disorder;which could be contributing or causing psychiatric presentation

• mental status exam:general appearance, behaviour, cooperation, speech, mood and affect, thought

content and form, perceptual disturbances, cognition (including MMSE if indicated), judgment,

insight, reliability

Investigations

• investigations vary with age, established psychiatric diagnosis vs. first presentation, history and

physical suggestive of organic cause

• as indicated:blood glucose, urine and serum toxicology screen, pregnancy test, electrolytes,TSH,

AST/ALT, bilirubin,serum Cr,BUN,and osmolality

• blood levels of psychiatric medications

• CT head ifsuspect neurological etiology

• LP if indicated (anti-NMDA receptor encephalitis)

Key Functions of Emergency

Psychiatric Assessment

• Is the patient medically stable?

• Rule out medical cause

• Is psychiatric consult needed?

• Are there safety issues(SI.HI)?

• Is patient certifiable? (must

demonstrate risk (present/past test)

and apparent mental illness(future

test))

zed or catatonic

Psychiatric Review of Systems

MOAPS

Mood

Organic

Anxiety

Psychosis

Safety

Acute Psychosis

Differential Diagnosis

• primary psychotic disorder (e.g.schizophrenia)

• secondary to medical condition (e.g.delirium)

• drugs:substance intoxication or withdrawal, medications (e.g.steroids, anticholinergics)

• infectious (CNS)

• metabolic (hypoglycemic, hepatic, renal,thyroid)

• structural (hemorrhage, neoplasm)

• autoimmune (anti-NMDA receptor encephalitis)

Management

• violence prevention

remain calm, empathic, and reassuring

ensure safety of staff and patients, have extra staff and/or security on hand

patients demonstrating escalating agitation or overt violent behaviour may require physical

restraint and/or chemical restraint

• treat agitation: whenever possible,offer medication to patients as opposed to administering with force

(helps calm and engage patient)

• benzodiazepines: lorazepam 2 mg PO/IM/SL

• antipsychotics: olanzapine 5-10 mg PO/IM, haloperidol 5 mg PO/1M

• treat underlying medical condition

• psychiatry or Crisis Intervention Team consult

Suicidal Patient

Epidemiology

• attempted suicide 1

;

>M, completed suicide M >l

;

• second leading cause of death in people <24 yr

• significantly increased incidence among marginalized communities, particularly Indigenous peoples

and 2SLGBTQQIA Canadians

See Psychiatry.Common forms, PS62 +

fot certification (involuntary assessment/

admission) considerations

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ER57 Emergency Medicine Toronto Notes 2023

Management

• ensure patient safety: close observation, remove potentially dangerous objects from person and room

• assess thoughts (ideation), means, action (preparatory, practice attempts), previous attempts,

protective factors

• admit if there is evidence of: active intent and organized plan, access to lethal means, psychiatric

disorder, intoxication (suicidal ideation may resolve with few days of abstinence)

• patient may require certification (completion of forms I and 42) if unwilling to stay voluntarily

• do not start long-term medications in the ED

• psychiatry or Crisis Intervention Team consult

High-Risk Patients

SAD PERSONS

Sex - male

Age >45 yr

Depression

Previous attempts

Ethanol use

Rational thinking loss

Suicide in family

Organized plan

No spouse, no support system

Serious illness

Common Paediatric ED Presentations

Modified Glasgow Coma Score

Table 36. Modified GCS

Modified GCS lor Inlants

Eye Opening

4 - spontaneously

3 -to speech

2 -to pain

1- no response

VerbalResponse

5 - coos,babbles

4 -irritable cry

3 - cries to pain

2- moans to pain

1- no response

Motor Response

6 -normal,spontaneous movement

5 - withdraws to touch

4 - withdraws to pain

3 - decorticate flexion

2 -decerebrale extension

1- no response

Any trauma or suspected trauma

patient <1yr with a large,boggy scalp

hematoma requires U/Sor CT

Modified GCS forInfant|<2 years)br Non verbalPatients

Eye Opening

4 -spontaneously

3 -to speech

2 -to pain

1-no response

Motor Response

6 -normal,spontaneous movement

4 -confused speech,disoriented,consolable 5 -localizes to pain

3 -inappropriate words,not consolablefaware 4 - withdraws to pain

3 -decorticate flexion

2 -decerebrale extension

1- no response

VerbalResponse

5- oriented,social,speaks,interacts

2 -incomprehensible,agitated,restless,

not aware

1- no response

Consider Alert.Pain. Verbal,Unconscious<AVPll) scale

Respiratory Distress

• see Paediatrics, PRO, P93

History and Physical Exam

• infants not able to feed, older children not able to speak in full sentences

• anxious, irritable,lethargic - may indicate hypoxia

• tachypnea >60 (>40 if preschool age, >30 ifschool age), retractions, tracheal tug

see Paediatrics, P3 for age specific vital signs

• pulsus paradoxus (rarely used clinically)

• wheezing, grunting, vomiting

Table 37. Stridorous Upper Airway Diseases:Differential Diagnosis

Feature Croup Bacterial Tracheitis Epiglottitis

Age Range|yr)

Prodrome

Temperature

Radiography

Etiology

Barky Cough

Drooling

Appear Toxic

Intubation/ICU

Antibiotics

NOTE

0.5 4 S 10 28

Mild for days then acutely severe Hours to days

Low grade

Steeple sign

Parainfluenza

Mmulcs to hours

High High

Exudates intracheat

S. ouieusMS

Thumb sign

H.inlluenioe typeb

Yes Yes No

Occasionally No Yes

No Yes Yes

No but yes if severe (rare) Yes Yes

No Yes Yes

r T

Oral exam Oral exam No oral exam,consult ENT L J 1

flow rare withHib vaccine in common use

found asdiffuse haziness and irregularity of the anterior wall of trachea:consider imaging only after ruling out epiglottitis

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Management

• croup (usually laryngotracheitis caused by parainfluenza viruses)

• dexamethasone x 1 dose

if moderate-severe, add nebulized or MDI epinephrine (racemic has limited availability)

consider bacterial tracheitis/epiglottitis if unresponsive to croup therapy

humidified O’

has no evidence for efficacy

• bacterial tracheitis

airway maintenance - usually require intubation, ENT consult, ICU

start antibiotics(e.g.doxacillin), pending C&S

• epiglottitis

• •) D'

s: drooling, dyspnea, dysphagia, dysphonia + tripod sitting

• do not examine oropharynx or agitate patient

• immediate anesthcsia/ENT call

-intubate

• then IV fluids, antibiotics, blood cultures

Febrile Infant and Febrile Seizures

FEBRILE INFANT

• for fever >38°C without obvious focus

• <28 d

admit

full septic workup (CBC and differential,CRP, blood C&S, urine C&S, LP ± stool C&S, CXR if

indicated)

treat empirically with broad spectrum IV antibiotics (ampicillin, and ceftazidime or cefepime

or cefotaxime (if available) or gentamicin (add acyclovir or vancomycin when indicated))

• 28-90 d

• as above unless infant meets Rochester criteria, if so, complete a partial septic workup (CBC

and differential, blood C&S, urine C&S,CXR if indicated)

• antibiotics(ceftriaxone or cefotaxime (if available), add acyclovir or vancomycin when

indicated)

- >90 d

toxic:admit, treat,full septic workup

non-toxic and no focus:investigate as indicated by history and physical

antibiotics(Ceftriaxone or cefotaxime (if available), add acyclovir or vancomycin when

indicated)

FEBRILE SEIZURES

• see Paediatrics, P88

Etiology

$

• children ages 6 mo-6 yr with fever or history of recent fever

• typical vs. atypical febrile seizures

• normal neurological exam afterward

• no evidence of intracranial infection or history of previous non-febrile seizures

• often positive family history of febrile seizures

• relatively well-looking after seizure

Rochester Criteria for Febrile Infants

Ages 28-90 Days Old

• Helps identify SBI (serious bacterial

infection) and guide testing/work-up

for well-looking febrile neonates

• Non-toxic looking

• Previously well f>37 wk gestational

age. home with mother, no

hyperbilirubinemia, no prior

antibiotics or hospitalizations, no

chronic/underlying illness)

• No skin,soft tissue, bone, joint, or

ear infection on physical exam

. WBC 5000 15000. bands <1500,

urine <10 WBC/HPF.stool <5 WBC/

Investigations and Management

• if confirmed febrile seizure:treat fever and look forsource of fever

• if not a febrile seizure:treat seizure and look for source of seizure

note: may also have fever but may not meet criteria for febrile seizure

• ± LEG (especially if first seizure), head U/S (if fontanelle open)

HPF

Table 38. Typical vs. Atypical Febrile Seizures

Characteristic Typical Atypical

Duration

Type of Seizure

Frequency

<5 min

Generalized

1in 24h

>5 min

Focal features

»1in 24 h

rt

LJ

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ER59 Emergency Medicine Toronto Notes 2023

Abdominal Pain

• see Paediatrics, P46

History

• neuro, infections, autoimmune, hematology, trauma, abuse Hx questions

• nature of pain, associated fever

• associated Gl, GU symptoms

• anorexia, decreased fluid intake

• stress and/or social issues (most common in middle aged children)

Red Flags (or Abdominal Pain

• Significant weight loss or growth

retardation (need growth chart)

• Fever

• Joint pain with objective physical

findings

• Rash

• Rectal bleeding

• Rebound tenderness and radiation of

pain to back,shoulders,or legs

• Pain wakes from sleep

• Severe diarrhea and cncopresis

Physical Exam

• HEENT, respiratory, abdominal exam including ORE, testicular/genital exam

Table 39. Differential Diagnosis of Abdominal Pain in Infants/Children/Adolescents

Medical Surgical

Colic Malrotation with volvulus

Hirschsprung's disease

Nccrotiring enterocolitis

Incarcerated hernia

Intussusception

Duodenal atresia

Appendicitis

Cholecystitis

Pancreatitis

Adnexal torsion (testicular or ovarian)

Ectopic pregnancy

Trauma

Pyloric stenosis

DTI

Constipation

Gastroenteritis

Sepsis

Henoch-Schonlein purpura

ac

Hemolytic uremic syndrome

Pneumonia

Strep throat

Sickle cell disease crisis

OKA

Functional

'Remember to keep an index ol suspicion tor child abuse

Common Infections

• see Paediatrics. P62

Table 40. Antibiotic Treatment of Paediatric Bacterial Infections

Infection Pathogens Treatment

MENINGITIS SEPSIS

Group 8 Streptococcus (GBS),f. coli. Listeno.Gramnegative bacilli

Same pathogens as above and below

ampicillin * Neonatal cefotaxime

1-3 mo celtriaxone/cefotaxrme vancomycin ampicillin (if

immunocompromised)

ceftriaxone *

>3mo S.pneumoniae, H. influenioe type B (>Syr). vancomycin

meningococcus

OTITIS MEDIA

1st Line 5.pneumoniae,H.influenioe type B,

M. calarrholis

amoxicillin 75-90 mg/kg/d BID

OR 45-60 mgfkg/day TID

1.cefuroxiine axettl 30 mg/kgld BI0/TI0

OR ceftriaxone SO mgikg/daylM x 3 d (if minor allergy)

2. clarithromycin 15 mg/kg/d BID (lor severe allergy)

7:1amoxicillin to davulanateratio

<35 kg:45-60 mg kgd TID

»35 kg: 50 mg P0 TID

1st Line with

Penicillin Allergy

Treatment Failure

STREP PHARYNGITIS

Group A P-hemoly tic Streptococcus penicilltn/amoxicrllin. celalexin. or erythromycin (can

cause Gl upset)

DTI

l.coli,Proteus, H.influenioe, Pseudomonas,S.

soprophyticus.(nletococcus. CBS

Oral: celalexin

IV:aminoglycoside (gentamycin) t ampicillin

PNEUMONIA

1-3 mo Viral,S. pneumoniae. C.trachomotis,B.pertussis,S.

oureus, H.influenioe

Vital,S. pneumoniae. S. oureus, It.influenioe.

Mycoplasma pneumoniae

As above

cefutoxime *

macrolide (erythromycin)

OR ampicillin± macrolide

ampicillin/amoxicillin or cefutoxime

r n

L J 3 mo-5 yr

>5 yr ampicillin/amoxicillin macrolide

OR cefuroxime macrolide

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ER60 Emergency Medicine Toronto Notes 2023

Child Abuse and Neglect

Association of 2 SocialNeeds Interventions

with ChildEmergency Deportment Use and

Ho spitaliiotions

JAMA Pediatr. Published online AprilIt. 2022

do;:10.1001/jemaptdratri(i.2022.0S03

Purpose: tolink social needs interventions to

healthcareoutcomesamong paediatric populations.

Methods: 604 chikkaregirer pairs were randomired

to groups in which they are given a socialresources

handout ($RH) withand without the help ola patient

navigator support.

Results:Ojrmg the 00d of follow-up,pans that

navi gated the S8H alore were associated with

increased probability of hospitalization when

compared to those grren professional help.

• see Paediatrics. P18

• obligation to report any suspected/known case of child abuse or neglect to CAS yourself (do not

delegate)

• document injuries

• consider skeletalsurvey x-rays (especially in non-ambulatory child), ophthalmology consult,Ci head

• injury’patterns associated with child abuse

HI: torn frenulum, dental injuries, bilateral black eyes, traumatic hair loss, diffuse severe CNS

injury, retinal hemorrhage

• Shaken baby syndrome: diffuse brain injury,subdural/SAH, retinal hemorrhage, minimal/no

evidence of external trauma, associated bony fractures

skin injuries:bites, hruises/burnsin shape of an object, glove/stocking distribution of burns,

bruises of various ages, bruises in protected areas

bone injuries: rib fractures without major trauma, femur fractures <1 yr,spiral fractures of long

bones in non-ambulatory children, metaphyseal fractures in infants, multiple fractures of various

ages, complex/multiple skull fractures

GU/GI injuries:chronic abdominal/perineal pain, injury to genitals/rectum, ST'

l/pregnancy,

recurrent vomiting or diarrhea Presentation of Neglect

• Failure to thrive,developmental

delay

• Inadequate or dirty clothing,poor

hygiene

• Child exhibits poor attachment to

parents

Common Medications

Table 41. Commonly Used Medications

Drug Dosing Schedule Indications Comments

Acetaminophen

Activated charcoal

325-650 mg P0 q4-6h PRN

30-100 gPO in 250mlHtO

Pain control

Poisoning/overdose

Max 4 g daily

Ellicacy and safety are case-dependent and

are a source ol debate

Procedures that may Require Sedation

• Setting fractures

• Reducing dislocations

t Draining abscesses

• Exploring woundsfulcers/superficial

infections

• Endoscopic examination

• Reduce patient anxiety/agitation for

imaging/procedures

325 650 mg P0 q4 h max 4 gfd

stroke/MI risk:81-325 mg PO once

daily

160 mg cheered

5mg slow IV q5 min x3 if no

contraindications

ASA Pain control

Prevention ol adverse cardiac

events

ACS

(3-blockcrs

(metoprolol)

Acute Ml

CAD

Or

25 mg PO BID up to 100 mg PO BID

anxiety:2*10 mg PO TID/010

alcohol withdrawal:10-20 mg PO/IV

q1h titrated tosignsfsymptoms

1mg kg SC BID

Diazepam Anxiety

Alcohol withdrawal

Enoxaparin Acute Ml

DVT Prophylaxis/treatmenl

anaphylaxis:0.3 0.5mg IM:ACLS Anaphylaxis.ACLS cardiac arrest,

cardiac arrest:1mg IV q3-5 min ACLS ACLS bradycardia

bradycardia: 2-10 pg/rtnn IV infusion Hypotension

0.5-1.0 pg/kglV

Epinephrine Maxlmgfdose

fcnlanyl Procedural sedation

Pain control

Very short acting narcotic

(complication~apnea)

Benzodiazepine antagonist

Can cause seizures/status epileplicus in

chronic benzodiazepine users

Monitor lor electrolyte imbalances:also

risk of ototoxicity with high dose

In conjunction with Insulin for hyperkalemia

Monitor for side effects if prescribing

to a pdlienl with Parkinson’s disease

(cxtrapyramidal side ellects):results in CNS

depression

Flumazenil 0.3 mgIV bolus q5 min x3 doses Reversal of procedural sedation

furosemidc (Lasix ) CHF: 40 -80 mg IV

HTN:10-40 mg P0 BID

0.5-1.0 g/kg (1-2 mUkg)IV of D50W

CHF

HIM

Glucose

Halopcridol

Hypoglycemia/DKA

Psychosis

Cannabis Hyperemesis Syndrome

(anyH/ V)

Sedation

Mild to moderate acute pain

Analgesic and anti-inflammatory

properties

Hyperglycemia

CCBBB overdose

2.5-5.0 mg PO/IM initial effective

dose

6-20 mgfd

Ibuprofen 200-800 mg PO1ID PRN max1200

mq/d

bolus 5-10 U|0.2 U/kg)

then 5-10 U (0.1U/kg) per h

Insulin Monitor bloodglucose levels

Consider K*

replacement,alsomeasure

blood glucose levels before administration

Contraindications include:peanul/soy

allergy

Caution with narrow-angle glaucoma

Not to be used inlingers,nose,toes,

penis,ears

r m

Ipratropium bromide 2-3 puffs inhaled TID-OID.max12

puffsJd

Asthma lJ

lidocainewithepi max 7 mg/kg SC local anesthetic

+ max 5 mg/kg SC

anxiety:0.5-2 mg P0/IM/IV q6 8 h

status epileplicus: 4 mgIV repeat

up to q5 min

Lidocainew/oepi

lorazcpam

Local anesthetic

Anxiety

Status epileplicus

Alcohol withdrawal

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Table 41. Commonly Used Medications

Drug Dosing Schedule Indications Comments

Short acting benzodiazepine (complication

- apnea when used with narcotic)

Fentanyl and midazolam often used

together for procedural sedation

Glandconstipation side effects

DO KOI CRUSH,CUT,orCHEW

Risk of tolerance

Midazolam 50 pg/kglV Procedural sedation

Sedation for agitation

Morphine 10-30 mg P0 g4h

2.5-5 mgIV q4h

Mild to moderate acute/chronic

pain

Prescribed in combination with

NSAIDs or acetaminophen

0.5-2 mg or 0.01-0.02mg/kg initial Comatose patient

bolus

IV/IM/SL/SC or via ETT (2-2.5*

IV

dose),increase dose by 2 mg until

response/max10 mg

If patient is a chronic opioid user begin

with very small doses,and go up with small

increments as needed

Naloxone

Opioid overdose

Reversal in proceduralsedation

Nitroglycerin acute angina:0.3-0.G mgSL q5 min. Angina

OR Spgfmin IV increasing by 5-20 pg/ Acute Ml

Heart failure

Moderate pain control

Not to be used with other antihypertensives

Not in right ventricular Ml

min q3-5 min

Percocet 10/325 1-2 tabs POqGhPRN Oxycodone acetaminophen

Max 4 g acetaminophen daily

Begin maintenance dose 12h after loading

dose

Continuous ECG.6P monitoringmandatory

Phenytoin Status epilepticus:seefob/e 17.IRIS Status epilepticus

Epilepsy

Superficial infections

Proceduralsedation, also

refractory status epilepticus

Rapid sequence intubation

Apply to affected area BID/ TID

0.25-1mg/kgIV

Polysporin

Propofol

&

Short acting

Aneslhelic/sedalive (complication - apnea,

decreased BP)

Salbutamol 2 puffs inhaled q4-6 h max12 puffs/d Asthma Caution vrith cardiac abnormalities

Reactive airways

Thiamine 100 mg IV/IM initially,then 50-100 To treatr'prevent Wernicke’s

encephalopathy

Caution use in pregnancy

mg

IM/IV/P0 once daily x3 d

Tylenol

*

3 1-2 tabs P0 q4-6 hPRN Pain control Acetaminophen

*