A woman who is found unconscious at home is rushed to the ED. A STAT ABG (arterial blood gas) done shows acidosis and low pO2, high pCO2.
What is the most likely diagnosis?
Correct Answer B: With tricyclic antidepressant (TCA) overdose, symptoms typically occur within 2 hours of ingestion, which corresponds to the peak tricyclic antidepressant serum level, which may range from 2-12 hours.
Symptoms include: palpitations, chest pain, hypotension, decreased mental status and respiratory depression. ABG will show of acidosis and hypoxia.
→ Theophylline overdose leads to respiratory alkalosis.
→ Hyperventilation would show an alkalosis on ABG.
→ ASA toxicity - Initially, a respiratory alkalosis develops secondary to direct stimulation of the respiratory centers. This may be the only consequence of mild salicylism. The kidneys excrete potassium, sodium, and bicarbonate, resulting in alkaline urine. (A severe metabolic (ketolactic) acidosis with compensatory respiratory alkalosis may develop with severe salicylate intoxication).
From among the drugs listed below, which would be the cause for most concern in an overdose?
Correct Answer B:
Tricyclic antidepressant overdose is a significant cause of fatal drug poisoning. The severe morbidity and mortality associated with these drugs is well documented and due to their cardiovascular and neurological toxicity. Additionally, they are a serious problem in the pediatric population due to their inherent toxicity and the availability of these in the home when prescribed for bed wetting and depression.
The central nervous system and heart are the two main systems that are affected. Initial or mild symptoms include drowsiness, a dry mouth, nausea, and vomiting. More severe complications, include hypotension, cardiac rhythm disturbances, hallucinations, and seizures. Electrocardiogram (ECG) abnormalities are frequent and a wide variety of cardiac dysrhythmias can occur, the most common being sinus tachycardia and intraventricular conduction delay (QRS prolongation). Seizures and cardiac dysrhythmias are the most important life threatening complications.
→ Death caused by other choices is uncommon.
A 17-year-old girl presents to the ED. On exam she has pinpoint pupils and abnormal behavior.
What is the most appropriate test to order at this time?
Correct Answer A:
This teenage girl is likely abusing drugs, in particular heroin.
Opioids have many effects. They are strong sedating drugs and cause people to become quiet and introspective. Opioids may also produce euphoria, sometimes simply because severe pain has finally been relieved. The dull pain may enhance sexual pleasure.
They also cause constipation, flushed or warm skin and lowered blood pressure, itching, constricted pupils, slow, shallow breathing, a slow heart rate, and low body temperature. Opioids may cause confusion, especially in older people.
Many complications can arise from opioid addiction, especially if the drugs are injected with shared unsterilized needles. For example, viral hepatitis, which causes liver damage, can be spread through shared needles. Infections can occur at the site of injection or be carried through the bloodstream (sepsis), causing infections in the brain and bones.
In a bulimic patient, what medication is likely to help the most?
Correct Answer D:
Bulimia nervosa is recurrent episodes of binge eating followed by self-induced vomiting, laxative or diuretic abuse, vigorous exercise, or fasting.
Most symptoms and physical complications result from purging. Self-induced vomiting leads to erosion of dental enamel of the front teeth and to painless salivary gland enlargement. Serious fluid and electrolyte disturbances, especially hypokalemia, occur occasionally.
The diagnosis is suspected when patients express marked concern about weight gain and have wide fluctuations in weight, especially with excessive laxative use or unexplained hypokalemia. Swollen parotid glands, scars on the knuckles (from induced vomiting), and dental erosion are danger signs.
Treatment is with psychotherapy and SSRIs, especially fluoxetine.
In a bulimia nervosa patient who admits to binge-purge behavior and denies abusing laxatives all of the following can occur, except:
Correct Answer E:
Patients typically describe binge-purge behavior. Binges involve rapid consumption of food, especially high-calorie foods, such as ice cream and cake. Binges vary in amount of food consumed, sometimes involving thousands of calories. They tend to be episodic, are often triggered by psychosocial stress, may occur as often as several times a day, and are carried out in secret.
Most symptoms and physical complications result from purging. Self-induced vomiting leads to erosion of dental enamel of the front teeth and to painless salivary gland enlargement. Serious fluid and electrolyte disturbances, especially hypokalemia and metabolic alkalosis, occur occasionally due to vomiting potassium and protons.
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