Toxicology, Critical Care, Pregnancy/Lactation,Pediatrics, Vaccines

Which of the following is an antidote for acetaminophen toxicity A) RabAvert B) Atropine C) N-acetylcysteine D) Flumazenil

C) N-acetylcysteine First dose is 140mg/kg x1, 70mg/kg every 4 hours x 17 additional doses. Repeat the dose if emesis occurs within 1 hour of administration.

IgG

Carimune, Gammagard, Flebogamma DIF. Use IBW to calculate dose and uses slower infusion rate in renal and cardiovascular disease. *BLACK BOX WARNING* Acute renal dysfunction within 7 days of use that is associated with fatalities. Use w/ caution in elderly patients renal disease, diabetes mellitus, volume depletion, sepsis, and nephrotoxic medications. Monitor renal function, urine output, and volume status.

Non-depolarizing NMBAs

Cisatracurium (Nimbex), Rocuronium (Zemuron),

Which of the following is an inhaled anesthetic. *Select all that apply* A) Xylocaine B) Marcaine C) Naropin D) Suprane

D) Suprane (desflurane) Another is Sevoflurane (Ultane)

Which of the following is appropriate for pain management during pregnancy. A) ibuprofen B) naproxen C) aspirin D) acetaminophen

D) acetaminophen

Methylene blue usage as an antidote for methemoglobinemia (altered hemoglobin) is contraindicated in patients with ___deficiency

G6PD

___ are first line for analgesia

Opioids ( morphine, fentanyl, hydromorphone)

Isoniazid intoxication reverses with ___

Vitamin B6 (pyridoxine)

Commonly used local anesthetic

Xylocaine (lidocaine)

Systemic drugs not recommended in pediatrics

- Quinolones - Tetracyclines - Promethazine - Codeine

Dose of norepinephrine required for vasodilation.

0.1-0.3 mcg/kg/min

The dose of activated charcoal

1 g/kg This should be administered within *1* hour of injection of suspected toxin for maximum efficacy. Remember activated charcoal does *NOT* bind heavy metals (iron,lead,lithium,&mercury), corrosives (alkalis,acids), or alcohols.

Dose of acetaminophen for pediatrics

10-15 mg/kg/dose

Sedative(s) associated with improved ICU outcomes, decreased ventilator days, and decreased length of stay *select all that apply* A) Diprovan B) Precedex C) Ativan D) Etomodate

A) Diprovan (propofol) B) Precedex (dexmedetomidine)

Black Widow spider bites antidote A) RabAvert B) Antivenin C) N-acetycysteine D) protamine

B) Antivenin Can also reverse snake bites except copperhead and rattlesnakes (Use CroFab)

___ can cause propylene glycol toxicity at total daily doses as low as 1 mg/kg/day. A) Valium B) Ativan C) Restoril D) Diprivan

B) Ativan (lorazepam) Caution in potent CYP 3A4 inhibitors

Which of the following is an antidote for organophosphate (industrial insecticides) toxicity A) RabAvert B) Atropine & pralidoxime C) N-acetylcysteine D) Flumazenil

B) Atropine & Pralidoxime (DuoDote, ATTNAA) OPs block acetycholelesterase which causes a buildup of ACh levels. Atropine is an anticholinergic that blocks the SLUDGE effects of ACh. Pralidoxime treats muscle weakness and relieves paralysis of respiratory muscles secondary to toxicity

Which of the following is appropriate for the treatment of GERD/Heartburn during pregnancy A) esomeprazole B) calcium carbonate C) prilosec D) desomepreazole

B) calcium carbonate Lifestyle changes are always first and foremost, but if that fails calcium carbonate is next up.

Which of the following electrolyte disorders is caused by fluid overload, cirrhosis, heart failure, or renal failure. A) hyoptonic hypovolemic hyponatremia B) hypotonic hypervolemic hyponatremia C) hypotonic isovolemic (euvolemic) hyponatremia

B) hypotonic hypervolemic hyponatremia Treat with diuresis w/ fluid restriction or arginine vasopressin (AVP)

Nicotine overdose can be remedied with _____

supportive care & atropine

At higher doses, dopamine's agonism of ___receptors is responsible for its vasopressor effects for use in septic patients A) alpha B) beta-1 C) dopaminergic (D1)

*A) alpha* Beta-1 receptor agonism produces positive inotropic effects at medium doses. D-1 receptor agonism cause vasodilation in the kidneys at low doses.

Principles for treating shock

*Fill the tank* (30mL/kg crystalloid bolus prn to a CVP >8mmHg) *Squeeze the pipes* (use peripheral vasoconstrictor to increase systemic vascular resistance (SVR) ) *Kick the pump* (use beta-1-agonist to increase myocardial contractility and cardiac output)

Antidote for ethanol poisioning

-supportive care - banana bag (w/ b1 to prevent Wernicke encephalopathy if patient is a chronic user) - correct hypoglycemia

Dose of epinephrine required for vasodilation

0.1-2 mcg/kg/min (ACLS 1mg IV q3-5 mins)

When serum Mg is <__mEq/L w/ life-threatening symptoms (seizures or arrhythmias), IV replacement with Magnesium sulfate is recommended for __ days.

1 mEq/L. Therapy should continue for 5 days.

When serum phosphorus is <___ mg/dL, IV phosphorous replacement therapy is required. Full replacement makes ___ or longer.

1 mg/dL. 1 week or more.

Phenylephrine dose required for vasodilation

0.5-9 mcg/kg/min

a peripheral line must have an infusion rate <_mEq/L for hypokalemia.

10 mEq/hr with a max concentration of 10mEq/100mL. Faster infusion rate requires a central line with progressive cardiac monitoring.

Dose of dopamine required for vasodilation

10-20 mcg/kg/min

1 mEq/L in serum K below 3.5mEq/L is a total body deficit of ___ to ___mEq

100-400 mEq

You cannot correct sodium more rapidly than __mEq/L over 24 hrs.

12 mEq/L. Anything over that can cause osmotic demyelination syndrome which can cause paralysis, seizures, and death.

Dosing of Synagis (Palivizumab)

15mg/kg monthly in the anterolateral thigh muscle (neonates & infants) during RSV season. No more than 5 monthly doses during the RSV season.

First line treatment for cough and cold in pregnancy

1st generation antihistamines (*Chlorpheneramine* or diphenhydramine)

Precedex infusions should not exceed ___ hours

24 hours. For use in intubated and non-intubated patients. Dexmedetomidine- Alpha-2-agonist used for sedation.

The only drug approved form enuresis in pediatric patients

desmopressin. Positive reinforcements, normal daytime voiding, & normal hydration patterns are preferred.

T/F. ADHF Patients with hypotension, decreased renal function, AMS, and/or cool extremities have hypo perfusion and can be treated with vasodilators.

false. Vasodilators will decrease BP and worsen hypo perfusion. Use vasopressors.

Preferred hypothyroid treatment in pregnant women

levothyroxine

Patients with ADHF *AND* edema or JVD (congested patients) should be treated with

loop diuretics vasodilators (nitroprusside, nitroglycerin, or nesiritide)

____ is preffered in the 2nd and 3rd trimester to treat hyperthyroidism

methimazole

Rocuronium, Vercuronium, and Pancuronium can be reversed with ___

neostigmine methylsulfate

Treatment of extravasation associated with vesicants

phentolamine, an alpa-adrenergic blocker.

___ is used to treat intestinal gas with infants post-feedings.

simethicone drops

The only depolarizing NMBA

succinylcholine (Quelicin)

Ibuprofen infant dosing

5-10mg/kg q6-8 hours

Folic acid requirements during pregnancy.

600 mcg/day. (400 mcg/day for women of child-rearing age)

T/F. Nitroglycerin in contraindicated in patients with SBP<__mmHg

90 mmHg. or concurrent use with PDE-5 inhibitors of riociguart. This medication can cause sever hypotension and increase intracranial pressure. Monitor HR and BP. Keep in a non-PVC container and special tubing. Can cause headache, hypotension, lightheadedness, tachycardia, tachyphylaxis.

What is the recommend temperature to see urgent care services for pediatric patients?

< 3 months 100.4 (rectal) 3-6 months 101 (rectal) >6 month 103 (rectal)

When is it okay to refer a pediatric patient to urgent care

< 3months and temp of 100.4 (rectally) 3-6 months and temp of 101 (rectal) >6 months and temp of 103 (rectally) Cough/cold symptoms w/ no improvement x 3 days blood in urine/feces inability to eat or drink rash abrasions limiping seizures

Treatment options for ADHF patients with hypoperfusion AND congestion

A combination of vasopressors or interpose with vasodilatory properties (dobutamine, milrinone)

Which of the following is an antidote for animal bites toxicity. *Select all that apply* A) RabAvert B) Atropine C) N-acetylcysteine D) HyperRAB S/D

A) RabAvert (Rabies vaccines) D) HyperRab S/D (human rabies immune globulin) *MUST BE GIVEN TOGETHER*

This inotrope with vasodilator effects is a beta-1-agonist that can turn slightly pink without losing efficacy A) dobutamine B) milronone

A) dobutamine Also has weak beta-2 and alpha-1 activity. May cause hyper/hypotension, ventricular arrhythmias, & tachycardia.

Which of the following electrolyte disorders is caused by diuretic use, salt wasting syndromes, adrenal insufficiency, blood loss, or vomiting/diarrhea. A) hyoptonic hypovolemic hyponatremia B) hypotonic hypervolemic hyponatremia C) hypotonic isovolemic (euvolemic) hyponatremia

A) hyoptonic hypovolemic hyponatremia Treat with sodium chloride containing solutions

Which of the following are treatment options for delirium in ventilated ICU patients. *Select all that apply* A) sedation with non-BDZs B) haloperidol C) quetiapine D) lorazepam

A) sedation with non-BDZs like propofol or dexmedetomidine (Precedex) C) Quetiapine B) Haloperidol (commonly used, but not recommended by delirium guidelines)

Which of the following are injectible anesthetics. *Select all that apply* A) Xylocaine B) Marcaine C) Naropin D) Suprane

B) Marcaine (Sensorcaine) C) Naropin (ropivacaine)

This inotrope with vasodilator effects is aPDE-3 inhibitor that must be dose reduced for renal impairment A) dobutamine B) milronone

B) Milronone Also causes hypotension and ventricular arrhythmias

Which of the following conditions are Vaprisol (conivaptan) and Samsca (tolvaptan) approved to treat A) hyoptonic hypovolemic hyponatremia B) hypotonic hypervolemic hyponatremia C) hypotonic isovolemic (euvolemic) hyponatremia

B) hypotonic hypervolemic hyponatremia C) hypotonic isovolemic (euvolemic) hyponatremia or SIADH Conivaptan is *contraindicated* in hypotonic hypovolemic patients and anuria. Tolvaptan is contraindicated in patients who can't respond to adequately to thirst and anuria. Has a warning of hepatoxicity. Avoid use >30 days. Both are associated with osmotic demyelination shydrome when hyponatremia is corrected too rapidly (>12 mEq/L/24 hrs)

___ can cause propylene glycol toxicity at doses as low as 1mg/kg/day due to it being formulated in propylene glycol A) midazolam B) lorazepam C) morphine D) fentanyl

B) lorazepam

Stimulant overdose from amphetamines, weight-loss drugs, cocaine, MDMA, etc can be treated wit ___-

BDZs (lorazepam), supportive care

Maintenance therapy for asthma control in pregnant women

Budesonide Rescue- albuterol

Which of the following electrolyte disorders is caused by SIADH. A) hyoptonic hypovolemic hyponatremia B) hypotonic hypervolemic hyponatremia C) hypotonic isovolemic (euvolemic) hyponatremia

C) hypotonic isovolemic (euvolemic) hyponatremia Treat with fluid restriction, diuresis, arginine vasopressin (AVP) , or demeclocycline (off label)

Which of the following is contraindicated in patient with hypersensitivity to egg or soy A) Valium B) Ativan C) Restoril D) Diprivan

D) Diprivan (propofol) Canc cause hypertriglycerideimia, green urine/hair/nail beds, & PRIS Discard vial and tubing within 12 hours of use to prevent bacterial growth due to it being an oil-in-water emulsion (opaque white).

Iron is reversed with

Deferoxamine (Desferal)

Insulin reversal

Dextrose

Antidote for digoxin

DigFab

Antidote for heavy metals

Dimercaprol Succimer (Chemet)

Which of the following medications is contraindicated in pregnancy A) hydroxyurea B) tetracycline C) quinolones D) methotrexate E) all of the above

E) all of the above Others include hormones, topical retinoids, misoprostol, paroxetine, RAAS inhibitors (ACEs/ARBs), Statins, Thalidomide, Topiramate, Valproic Acid/DIvalproex, Warfarin, weight loss drugs

T/F. Fluid resuscitation is only appropriate when a patient is hypovolemic due to hemorrhage.

False. Blood products should be administered in this situation. Fluid resuscitation is appropriate when hypovolemia is not associated with hemorrhage.

T/F. There is clear clinical benefit of using colloids over crystalloids.

False. Colloids contain larger molecules that remain in the intravascular space and increase oncotic pressure but show no clinical benefit. Crystalloids contain various concentrations of sodium and/or dextrose that pass freely between semipermeable membranes.

It is okay to use sorbitol to induce vomiting after toxin ingestion. T/F.

False. It can cause electrolyte imbalance.

T/F. Croup can be treated with ceftriaxone

False. It is an viral infection associated with stridor, barking cough, and hoarseness. Croup is treated with systemic steroid (Dexamethasone 0.6mg/kg) or racemic ephedrine nebulized.

T/F. It is okay to use metronidazole during pregnancy.

False. It should be avoided and breast milk should be discarded 12-24 hours after a single dose. Additional medications include amphetamines, ergotamine, lamotrigine, lithium, & statins.

Antidote for benzodiazepines

Flumazenil (Romazicon)

____ and ___ are recommended agents for prevention of stress-related ulcers.

H2RAs and PPIs Risk factors for stress ulcers include mechanical ventilation & coagulopathy

Preferred diabetes management in pregnant women.

Insulin, glyburide, & metformin

____ known to cause emergence reactions (vivid dreams, hallucinations, delirium)

Ketamine. Pretreat with BDZ to decrease incidence of emergence reactions.

Preferred hypertension treatment in pregnancy

Labetalol, methyldopa, nifedipine

Opioid antidote

NARCAN (Naloxone)

NMBA reversal agents

Neostigmine (Bloxiverz) Sugammadex (Bridion) both are acetylcholineesterase inhibitors.

Long term ___ treatment at high doses could lead to cyanide poisoning.

Nitroprusside. Adminiter Cyanokit (hydroxycobalmin). Do NOT use if solution is NOT dark red.

Vasopressor of choice during septic shock

Norepinephrine followed dopamine

___ is preferred in the 1st trimester to treat hyperthyroidism

PTU

___ indicated from the prevention of serious lower respiratory tract disease caused by RSV.

Palivizumab (Synagis)

Warfarin reversal agent

Phytonadione aka Vitamin K (Mephyton)

Only sedative approved for non-intubated patients

Precedex (dexmedetomidine)

Heparin reversal

Protamine 1mg will reverse 100 units of heparin

Anticholinergic overdose symptoms

Red as a beat (flushing) Dry as a bone (dry eyes, no sweat,dry skin) Blind as a bat (double/blurry vision) Mad as a hatter (delirium) Hot as a hare (fever)

Antidote for anticholinergic overdose (atropine, diphehydramine)

SUpportive care and rarely physostigmine (acetylcholinesterase inhibitor). Can administer BDZs if seizures are present.

Salicylates can be reversed with ___

Sodium bicarbonate

Hemostatic agents used to stop bleeding.

Tranexamic acid (Cyklokapron) Recombinant Factor VIIa (NovoSeven RT)

T/F. BDZs are used in the ICU to sedate patients with seizures or alcohol/BDZ withdrawal.

True

T/F. Patients on neuromuscular blocking agents (NMBA) must be adequately sedated and on analgesia as well as mechanically ventilated.

True

T/F. for general infection, penicillins, cephalosporins, erythromycin, and azithromycin are safe to use during pregnancy

True Do NOT use quinolones

T/F. magnesium is necessary for potassium uptake

True.

T/F. Nitroprusside requires protection from light

True. Any color shows degradation to cyanide. Administration details- Use lowest dose for short time due to ability to degrade to cyanide. Causes hypotension, headache, cyanide toxicity (especially in the renally impaired) Monitor BP (continuously, HR, renal/hepatic function, urine output, cyanide toxicity, acid-base status, venous oxygen concentration)

T/F. Ceftriaxone should be avoided in neonates.

True. Ceftriaxone displaces bilirubin from albumin which can cause brain damage.

T/F. Bacteriuria must be treated in pregnant women even if asymptomatic.

True. Cephalexin and ampicillin are preferred treatment. Nitrofurantoin & SMX/TMP should be considered last line during the 1st trimester and should not be used in the last 2 weeks of pregnancy.

T/F. Daily "Sedation vacations" are used to assess the readiness to wean off/stop the sedative.

True. It helps reduce duration of mechanical ventilation. Use the RAS and SAS scale to assess agitation and sedation.

T/F. Nonbenzodiazepines are first ling for managing agitation in critical care environments.

True. Propofol or dexmedetomidine is appropriate. BDZs are appropriate for patients with seizures or alcohol/BDZ withdrawal.

T/F. Extravasation is a medical emergency

True. Vasopressors are common vesicants that can cause extravasation.