PiPU

EMERGENCY MEDICINE

,
, guideline

PiPU
...
Pipu Tavornshevin
pipu@edu.vajira.ac.th (PBook Vajira BM19)
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Emergency Medicine
Hemorrhagic / Stroke / / Rabies / Tetanus / Anaphylaxis / Pain control / UTI / Pharyngitis / Sinusitis /
Cardio emer / GI bleed / Airway disease / Aortic emergency / Trauma / Foot and Shoulder injury / Head injury /
EMS / Hazardous material incident / Syncope / Geriatic medicine / / Toxico / Forensic Toxico

Hemorrhagic
ex. Ectopic pregnancy bradycardia vagal reflex pain

UA UPT U/S acoustic window organ

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Methanol > M/C CT brain = Putamen bleed/necrosis

Stroke
Stroke PCA miss Cerebellar stroke
vertigo (central vertigo peripheral )
/ /
Pitfall : Dimen 50mg IV, Betahistine 6mg 1x2(ENT )
Mx : cerebellar sign vermis/peripheral
Mimic stroke : 1st M/C Hypoglycemia
Mx : push glucose + cause infect >>> respi , GI , GU , skin&soft tissue ; source 4

Transamine bleed ex. Skull fracture ; 3hr : Load 1g then drip 1g in 8 hr

: suture ?, ?, > > stop bleed, TT ?,
Lidocaine onset <2min, duration 30-60min
S/E : arrhythmia, hypotension, CNS ** with adrenaline risk infect
( pneum) ; > raw surface > risk infect ; for cosmetic
subcu ? prone infect ( )
Non prone infect/cosmetic = subcut ; bleed subcu
Off stitch 5d + sterile stitch ( suture mark)
Fine extremities 10d off
blood supply + tension size
ATB LW, prone wound ; non prone wound infect
infect 1% 7% ; clean suture +/- ATB prophylaxis
- povidine or dilute 1:10
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Rabies : Ig IM - ERIG 40ml/kg > test 1amp = 1,000u

- HRIG 20ml/kg ;

> infiltrate nerve

: Vaccine - PCEC(purified chick embryo cell) ID 0.1ml 2 d 0-3-7- -28

- Verorab IM 0.5ml d 0-3-7-14-28

**Hamster bite (CDC) rabies incidence

Tetanus : TIG tetagram 250U IM ; TAT 1,500U <12 ( dose )

3,000U >12

: Toxoid 0.5ml IM at 0-1-6 month ; Arthus reaction

- prone wound 1. Wound depth >1cm 2. >6hr 3. Contaminate soil/saliva/feces
4. Dirty wound 5. Puncture/crush wound 6. Avulsion wound from burn/missile
- TT 2 3 2 ( course) = non-immune

Anaphylaxis : risk <16/ >30 , IV route Laryngeal edema

1. Likely allergen(ATB, sulfa, ) + 2/4 system

2. Not likely allergen + skin + 1/3 system

3. Known allergen( seafood) + BP drop

Tx : 1st airway ABC, expand volume 5-10ml/kg, early adrenaline Dx at ER time

Adrenaline IM (1:1,000) 0.3-0.5mg, 0.01mg/kg ;
10-15 Adre observe
1hr tachyphylaxis

3 dose
+ observe 4-6hr at ER for
>> IV : (1:10,000) 0.1ml/kg Adre 1amp NSS relapse
10ml IV slow push in 10min 3dose ; + D/C advice observe 72hr
drip for late phase( steroid)
Steroid Hydrocortisone 250mg IV ; Dexa 10 mg

Anti H1 1st Diphen 0,1mg/kg(Benadryl) > CPM
2nd Dimen
Anti H2 : Ranitidine ( )

Adrenaline Steroid Anti H1 Anaphy

Anaphylaxis : Adre 0.3-0.5, Dexa 8, Rani 50, CPM 10
Angioedema q 5 min if respi wheeze >
Urticaria
- Angioedema : ACEI, allergy

Tx : urticarial CPM steroid(hydrocortisone)

mucosa >> FFP bradykinin ; enz plasma

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Pain control synergist +/- adjunct(TCA, muscle relaxant)

Methysalicylate cream 30 mg 1 prn
Mydocalm(Tolperisone) 1x3 : muscle relaxant
Paracetamol 4g/d, max per dose = 600mg(10-15MKd)
(500) 1 or (325) 2 tab
NSAIDs 1. Ibuprofen (400) 1x3 PO pc ( syrup), ;
2. Diclofenac (25) 1x3 PO pc ;
** PPI
(75) IM stat ; IV arrhythmia ; 50
,
3. Indomet - 25 1x2 > gout attack

4. Ponstan 500
5. Naproxen 250 1x2
Migraine Naproxen(275 Synflex), Ibuprofen
GI risk : low NSAIDs alone
mod NSAID+PPI ; coxib
high coxib + PPI NSAID or weak opioid
Heart risk : Naproxen NSAID
**NSAIDS end of life care PU bleed, gastritis, renal fail
CHF salt water retention
CI : GI, , heart(HF, ischemia fluid retention), pregnancy(1st tri abort, 3rd tri - PTL)
Stroke(Plt aggregation), sulfa(-coxib, -xicam)
: ASA ( non spec, COX1 ) NSAID ( drug interaction)
; Naproxen ( 3)
PU : risk 4 1. >65 2. High dose NSAIDs
3. ASA/steroid/warfarin/anticog 4. PU with complication
** Hx PU
1 PU EGD
Opioid 1. MO 3-5 mg IV stat
MO(1:10) 10 mg + NSS 100 ml IV drip 5ml/hr(0.5 mg/hr) max dose S/E
- Opioid Acute pain
; max 0.1mg/kg q 3hr( )
> : antichol > bowel move (colo ) ( post op
), , BP drop(histamine), bronchospasm
2. Pethidine 20-30 mg IV prn q6hr potent
> : met > Norpethidine " 2 " ,
atropine > HR (vagolytic eff) opioid
3. Tramadol (50) 1x3 PO pc or 1 tab PO prn for pain q 8hrs
(100) IV stat (1amp = 2ml = 100mg)
4. Fentanyl s/e , no active met, onset CVS Patch 50g
Fentanyl (5:1) IV drip 5 ml/hr (= 25 g/hr)
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Opioid enteral 1. MO sulfate tab = MST (10) Bioavailability = 1/3 = long acting
10 mg/d >>> MST (10) 1x3 po pc = 30mg/d
- MST Basal q 12hr(sustain release) ; Kapanol 20mg capsule OD
- dose breakthrough 20% : 0.2x30 = 6mg
onset 15min , 2-4hr
>> MO syrup(1cc=2mg) MO syrup 3ml prn q 2-4hr if PS>7/10
Pt prn 4-5 dose Basal
**Neuropathic pain = TCA, SNRI, CBZ, Tramol

UTI Upper : chill , CVA tender, N/V E coli, FQ

Ex. Cef-3 14d, FQ 7d
Lower : dysuria Tx 1st Bactrim
> MRSA ? Ans = Bactrim

Pharyngitis Bact : Amoxi/Clav 10 1g 1x2 po pc(30-50MKD)

Strep pyo : Beta lactamase in vitro ; + clav
M/C viral, then
bact(strep gr A C G) Strep pneumo : PBP alteration > Amoxi high dose
H influ > Beta lactamase
Modified Centor Fever, no cough, LN +ve, Tonsil +ve
(Strep gr.A score) 1-2 + = Treat Viral
1-2 + / = Rapid test Strep A ;
** <3 Strep A generalized lymphadenopathy ; pharyngitis
4-5 : Tx ATB 2-3 : Rapid test if neg > send culture 0-1 : pharyngitis symptomatic tx
Symptomatic tx Para, Ibuprofen( bact para NSAID synergist )
> Kamillosan
Clinical judge : Dexa 4 mg iv stat ; controversy Pt
Sinusitis Amoxi 3g, Pharyngitis Amoxi 2g

Dx Acute rhinosinusitis 2major, 1major( facial pain) + 2minor

**viral URI suggest ABRS : worsening symptom after 5day, persistence of symptom >10d

in Adult : EPOS 2007 symptom + sign

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- Tx Acute RS: spontaneous resolution 46% mild case, no complication

get rid infect + I&D + tx underlying condition( , allergy)

intranasal steroid inflame , oral steroid if pain 3-5d

oral ATB short term + intranasal steroid

symptomatic : oral antiHis if allergy, decongestant if , nasal douch chronic

: ATB 10-14d 1st Amoxycillin ; high dose S pneumo

>> 3-5 switch 2nd line : Amoxyclav, 2nd gen Cep, 3rd line : Clinda + 3rd gen Cep

Chronic rhinosinusitis : Gran negative + Anaerobe

Tx : ATB at least 21d Amoxyclav, Clinda + Ciproflox, Macrolide + Metro
controversial infect [no ATB approved by FDA RCT]
- : Microbe(), Biofilm, Allergy, Asthma, ASA sensitivity, GERD, Super Ag

Biofilm = (glycocalyx, polysaccharide attach mucosal surface)

**Chronic RS Biofilm significant > Pseudo, S aureus biofilm

- Tx for Biofilm 1. Sx O2 cilia function

2. Surfactant baby shampoo irrigation 2/ 1L

( sinus )
3. ATB : Mupirocin lotion for S aureus 1/ 1L

4. Disrupt QS : Macrolide low dose (subtherapeutic) 3mo 1mo

Roxithro 150 1x2 >> 1x1
Chlarithro 500 1x1 >> 250 1x1
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How to choose Pt for Macrolide **Macrolide shrink polyp trial

: no allergic, negative culture, nasal steroid not effective, symptom domained by post nasal drip(stricky

secretion), facial pain, HA

[not favor in clear runny nose, sneezing, allergic, fungal RS, ciliary dyskinesia]

Treatment rhinosinusitis
Acute RS ATB 10-14d1st Amoxycillin Intranasal tx underlying symptomatic
: oral antiHis if allergy,
steroid condition(
decongestant if
3-5 switch , allergy)
, nasal douch
2nd line : Amoxyclav, 2nd gen Cep
chronic
FQ Levo, Clinda, Levo
Chronic With NP ATB 21d+ Consider ATB polyp recur
no ATB approved by FDA Macrolide
Without NP Long term Mac 3mo CT > Sx

Influenza
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Cardio emer
Bradycardia Symptomatic Atropine ; ischemia induce ischemia
> then Dopamine( keep BP ) / Epinephrine / Isoproterenol(2-10g/min)
> then Pacemaker
r/o 2nd Beta block ( Mobitz I
supranodal block)
brady
1 = sick sinus > confirm by EP(electrophysio) study
Tx AF with pause >5sec or AV block with pause >3sec

STEMI CAG : Tigagrelor 90mg Plavix death

fibrinolytic : Plavix 4tab <75 ; >75

NSTEMI Heparin 60IU/kg bolus, then 12 IU/kg drip

Enoxa 1mg/kg SC q 12 hr x 2-8d ; GFR<30 Heparin

Pro BNP CHF Hx PE

1st exclude : dyspnea >300
2nd <50 50-75 >75
450 900 1800 >> Likely CHF

Inotrope Dobutamine
BP drop
Ex. EF BP ok >> Dobutamine ;

>> Dopamine mod dose (5-10mg/kg) = (2:1) 7.5mg

Morphine histamine release BP drop

NTG 1. SBP<90
2. brady HR<50 or tachy HR>100
3. RV infarct Ste in V1 vasodilator
4. Hx on Viagra esp , sex ; Sildenafil 24hr, Tada 48hr

Cocaine STEMI
catechol > alpha vasospasm > MI , BP shoot
** cocaine induced MI : Beta blocker cocaine Alpha
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Syncope Sanfrancisco syncope rule = Syncope high risk serious outcome D/C
: C H E S S CHF, Hct<30%, EKG abnormal, shortness of breath, SBP<90mmHg
= 3 Lab CXR, CBC, EKG
DDx : TIA, seizure
W/U : cardiac cause : EKG, R/O aortic dissect, PE(, pulse 4ext, well score)
Noncardiac cause : M/C orthostatic hypotension, vagovagal attack(prove R/O
)
stroke Neuro
Seizure > Ca Mg P, Lactate, CK clinical

Ca gluconate Digoxin toxic[N/V/D, yellow vision, mental disturbance, HA]
, ,
stone heart(tetanic contraction)
Digoxin EKG effect : scooping pattern ;
strain patterin in RVH/LVH
Intox : (pathog)bidirectional VT, (high sense)PVC, (high spec)AT with block
2 : Aconite( )

UGIB
Variceal Octreotide 50g IV bolus, then 250g + 5DW 500ml(1:2) iv drip rate 50ml/hr x5d
50 drip 25
Prophylaxis ATB : Ceftri 1g iv OD or
Pen > Norfloxacin (400) 1x2 x 7d ( SBP) or Cipro 400 mg iv q 12 hr
Prophylaxis bleed : Propranolol (10) 1x2 po pc keep HR 55-60
If chronic alcohol : Thiamine 100mg iv OD x 3d
Non-variceal Omeprazole/Pantoprazole(Controloc) 80 mg IV bolus, then 80mg in 5DW 100 ml IV drip
80 drip 8
10ml/hr ; Panto Ome Ome
Blatchford score if >12 : plan EGD within 12hr
[ Bleed > BUN,Hb,BP,pulse Comp > Hepatic dz, HF, syncope]

Stress ulcer prophylaxis PPI NPO !!

1. illness : severe burn(>35%BSA), sepsis, RF(Cr>5.7 Plt dysfunction), liver fail, trauma

2. Mechanical ventilator >48hr (prolong) ; very high risk

3. Coagulopathy : INR >1.5, Plt<50,000 ; very high risk
4. GCS<10 , major head injury, NeuroSx, MI, spinal cord injury, shock
5. High dose steroid

- S/E : aspirate pneumonia, C difficile colitis, hypoMg if use>1mo

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Airway disease
SABA Good response : COPD/asthma
Poor response : pneumonia, cardiac wheezing ; Pt COPD heart dz EKG
CXR
Ventolin
- solution 0.03ml/kg + NSS upto 3ml ; 1cc=5mg 6-8LPM( 15micron particle)
- NB 0.1-0.15ml/kg + NSS ; 1NB = 2.5mg = 2.5ml
NB > hyperK dose 10-20mg = 4-8NB
; Berodual(ipratopium+fenoterol) - dose same NB solution
COPDAE Berodual[fenoterol + Ipratopium ; antichol admit+synergist]
severe AE( )
= + steroid
asthma : SABA Berodual ; antichol affinity Beta2 agonist
Mx : SABA 3 dose +/- antichol + 8mg Dexa + O2
+ IV Mg 1 ; 2nd time/1st time with PEF<60%
COPD precipitate infection 2/3 criteria ; criteria
1. Exacerbate/dyspnea
2. **strong
3.
ABG PCO2 60 40 20
Lung severe mod mild( )
; ABG normal PCO2 = 40 tube
Mg in asthma = 2mg
in SPE = 8mg ; S/E hyporeflex/conscious change > respi depress > EKG/cardiac arrest

Pneumothorax
clue for Primary SP : lung compliance
Secondary SP : ; CXR secondary
> >50, smoking, U/D lung

Tension pneumothorax Acute chest pain, pleuritic chest pain, dyspnea, cyanosis, syncope, cardiac arrest
General Hypoxemia, subcu emphysema, tachypnea
Chest sign Tracheal deviation, unilat expansion, hyperresonance on percussion,
tactile fremitus, decrease breath sound

CVS Tachycardia, hypotension, pulsus paradoxus
Hemodynamic monitoring : pulm diastolic P, CVP, CO

U/S lung point lateral , large = size >2cm

Seashore sign exclude 100% pneumothorax
Lack of lung DDx : pneumothorax, pleural adhesion, pulm infiltration/contusion, ARDS, atelectasis
sliding
**Pitfall : miss apical pneumothorax , subcu emphysema , chronic lung/high PEEP lung
sliding
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ICD : incision 1 rib > point ? spine

- Subcutaneous emphysema > Mx : no ICD, PEEP

Tx : 1. O2 high flow 100% diffuse( N2) space >

2. Control pain by opioid ; NSAIDs esp on ICD
3. Triflow 100 / ( 10 ) 1 1-2-3
- , observe 24hrs, no ATB
- F/U CXR 24 hr : expand = check circuit(mute ) or
F/U 24hr : clamp 4hr film ICD

- D/C F/U 2-4wk, / 2wk pleurodesis ; 12wk

Pleurodesis = PSP : Sx 90-100%, Med 75-90%

SSP : U/D Med or Sx

indication for Sx = Bilat SP

>> recurrent Bullae CT = Sx condition
ex. Case SP bilat > ICD 2 Med pleurodesis 2 recur thoracotomy
with pleurodesis ; Sx
= =
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Asthma exacerbation

severity : V/S , peak flow( ; ) ABG(if severe)

Mx on O2
beta 2 x 3 dose
systemic steroid
1hr: peak flow > beta2/antichol 1hr
PF >60% drip Mg 2g IV 20 min(counteract Ca at
peripheral airway ) monitor EKG dose
At 2hr V/S, PF
1. > D/C : MDI/accuhaler/tubuhaler , oral steroid 7d,
combination inhaler ICS/LABA (M/C revisit ),
F/U 1-2wk
2.
3. IV theophylline 5mg/kg in 1hr drip 10mg/kg in 24hr ; s/e monitor EKG ( ER, ICU)
D/C : ICS, oral CS 7d

ET tube non response medication, pH < 7.2, PaCO2 >5 mmHg, PaCO2 >55-70, PaO2<60
- adequate oxygenation, expi time I:E = 1:3, MV 6-8L/min, TV 5-7ml/kg

**Beta 2 hypoK

Reliever SABA2, LABA formoterol(Symbicot - SMART) S/E : tremor, tachycardia

Tx Antichol ipratropium(Berodual)
Controller
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COPD Dyspnea progressive, chronic cough/sputum, Hx risk factor(smoke, anthracosis), FHx COPD
Case 6hr progressive dyspnea ; COPD AE infect wheezing
DDx : heart, pneumonia, infected bronchiectasis, bronchitis, ...
CXR, EKG for r/o other disease
PE : Barrel chest, clubbing, , cyanosis, muscle wasting
CXR : AP Lateral - retrocardiac >2cm = increase AP diameter
Tx O2 keep 88-92, SABA + SAMA
systemic steroid 30 mg for 5days
ATB if increase sputum, purulence
gold guideline
- LABA : gold B = Indacaterol
Smoking cessation, pulmonary rehab, Flu/pneumococcal vaccination
NIV in COPD : success rate 80% respi acidosis, hospital stay, intubation rate
Pt severe(COPD AE, CHF, OSA)
+ , V/S stable, ,
COPD AE : severe if
- - PEF <100 - PR >120, hemodynamic unstable
- PaCO2 >45, pH <7.35 q - Sat <90 , PaO2 <60 - alteration of consciouseness - Rt HF

test spacer
MDI - no spacer - Spacer : prime dose 10-20
Tubuhaler particle MDI + spacer

Aortic emergency
Case 8hrPTA , U/D : HT, IHD
Ps 10/10
PE : BP 150/90, PR 90 loss of ext pulse
Back tender at L2-3, Neuro motor V/V and I/I, loss of pinprick below T10, loss of
sphincter tone, bulbocavernosus negative, DTR lower ext 0+
Imp : ruptured AAA
Risk factor AD HT 50-80%, age, sex >, preg 3rd tri with CNTD, FHx
Genetic trigger thoracic aortic dz : Marfan, Bicuspid aortic valve( turbulent > injury),
Ehler-Danlos
Congenital dz : Coarctation, Turner, TOF
Drug : cocaine, NMDA(ectasy)
Inflam dz : Giant cell arteritis, Takayasu arteritis, Bechet dz, Aortitis, Syphilis
S/S HT, sudden onset
( retroperitoneum) ;
Painless 2-10% >> syncope
PE : BP 4 Ext 20, 10, Pulse deficit 15-30%, radiofemoralpulse delay
Aortic murmur 1/3 : Cordi tendini ischemia
CHF 2nd to TAA > ischemia
CXR Widening mediastinum >8cm at T4
Normal CXR 15% Abnormal aortic/cardiac contour, Lt pleural effusion ( DDx AD, / )
Mx Pain control : opioid
BP : Betablocker Labetelol, Esmolol keep BP near normal
HR (]f shearing force) ;
Sx : type A>B
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AD > Vascular involvement

- coronary > MI RCA[inf-post wall]

> EKG : RV infarct V1-2 ST elevate

** Nitrate, MO BP drop
- spinal cord : paraplegia
- mesenteric : bowel ischemia
- Iliac : limb ischemia
- carotid : stroke > rt-PA bleed

AAA : >65 AAA 5-10%

>5.5cm or >1cm/yr
- Triad : Abd pain + HT + Pulsatile mass ; 1/3

- Miss Dx : Stone(AAA hematuria RBC 10-20 irritate), PU, MI, prolapse vertebral disc

- U/S

Female Acute epigastrium pain 1hrPTA radiating to back Awakening pain

DDx Heart MI / Vascular - dissect, aneurysm / GI
> EOD
Liver lab normal
pulse radio-femoral, radioradio, >> + bp 4 ext

U/S aorta epigastrium ; aorta spine + vein

: aorta 3cm( outer-outer) + flap ; r/o cyst by cut longitudinal 90'
Mx aortic dissect 1. HR (beta block ; esp iv or oral) shearing effect
2. BP Goal BP : SBP100-120 ; HR
3. Control pain by opioid

Aortic dissection Present with EOD

Standford A Abrupt severe chest pain Neuro syncope
Standford B Abdominal pain Neuro paraplegia
Aortic dissect > ST depress
Definite treatment : Sx dissect ascending aorta or
complicated descending aorta
[EOD ischemia, persist severe pain/HT, propagate dissect, aneurysm rupture/expansion]
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: Natear prn + Polyoph/Xanalin 1x4 + Histaoph 1x4

; 5 , +
Cellufresh ; Chloram ex. abrasion Dexoph glaucoma
Polyoph = ATB Xanalin Tobra = Tobramycin + Dexa
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Trauma

Form Primary survey

A Can talk, no stridor, on hard collar, > suction, get rid FB
B lung, RR, trachea, O2 sat, chest wall movement
PE for 5 life threatening
O2 mask with bag
C V/S, site bleeding, Blood volume 70ml/kg
Mx : open large caliber IV rate = /rate + + pressure x
14 / 150 + 80 cm + normal( cuff )
16 / 100
18 / 50
** 1,000ml +
**if shock > vv collapse femoral vein : ASIS pubic symphysis
G/M blood component 3 : O low titer, type spec ABO/Rh, cross match 1hr
source bleed : ext, int(FAST)
Stop bleed, response
D EMV, pupil, lateralization(DTR, motor, BBK), spinal cord injury level
E log roll, PR sp tone, prostate high riding, bulbocavernous reflex
Adjunct : EKG, Foley, X ray trauma : CXR, pelvis

RSI sedative + neuromuscular block intubation

difficult to intubation : LEMON or difficult to ventilate : MOANS
1. Preparation suction bag IV Team position Pt tube
Look
airway / ventilate
LEMON / MOANS
Evaluate 3-3-2 3 , mentu>floor 3 , >2
Mallampati Grade 3 / 4 5 / 20 %
Obstruction Neck mass
Neck mobility
Mask seal
Obesity
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Age >55
No teeth
Stiff lung ex. Ashthma/COPD
2. Preoxygenation 3-5 min, no PPV. Keep sat 100
3. Pretreatment sympathetic response BP/HR bleed stroke/MI/AoD
: Fentanyl 3mcg/kg, MO
4. Paralysis with Induct by Etomidate( hemodynamic, ) 0.3mg/kg
induction
MR by Succinylcholine 1.5mg/kg, onset 45-60sex, duration 5-10min
5. Protection and Sellick maneuver = cricoid cartilage
position

Trauma
A - inspi stridor >> C spine protect, definited airway ETT/cricothyroidotomy
** subcutaneous emphysema > ENT

emer > urgency
: Needle cricothyrodotomy medicut syringe 3ml ambule cricothyroid membrane
: ventilate - 1 4

B - check tube, decreased breath sound, lung sliding negative( FP one lung tube, fibrosis, chronic lung)
> ICD 500ml
C - blood loss grade ll ; blood volume 70cc/kg > for management ; conscious
- gun shot wound active bleed **FAST negative
retroperitoneum
D
E

Foot and shoulder injury

Rule out fracture : Ottawa rule

Shoulder Ant dislocation

: Dugas test ( ), Hamiltons Ruler sign deltoid, Ant fullness
: area supply axillary nerve(), pulse, joint above/below
** Fx /clavicle subcu emphysema > Dx pneumothorax
: Tx : countertraction , 20%rate recurrent
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Head injury : by severity trauma for Mx

GCS Head injury Indicated Mx case
13-15 Mild Observe neuro sign Alcohol/drug use , CT
X ray indicated
9-12 Moderate Admit observe O2 mask with bag
CT scan
<8 Severe(coma) ET intubation Evaluate/resus, neuro exam, iden associated injury
( gag reflex )
Ex. ICH GCS drop 15>11, pupil dilate fixed( hernia)
Mx : moderate head injury >> repeat CT scan, not ET intubation(GCS<8), mannitol (no hernia sign)

Indication for CT scan

high risk 5 GCS<15 for 2hr, neuro deficit, open skull fx, sign of base skull fracture, extreme age>65
Glasgow Neuro - Open skull & base - extreme age
Moderate risk 4 Dangerous mechanism(case ), vomiting>2phase( ICP), severe HA, retrograde amnesia
Danger vomit head - amnesia

EMS
: prehospital ambulance(ground, water)
2 : Field treat&stabilize - stabilize ER
Scoop&Run - OR/ward

1669 : ( resource/zone)
Star of Life EMS
1.early detection "" scene
: ??( > )
2.early reporting : 9 - - ( ) - / - ( CPR)
2 ;
3.early response : ; response 5
10 10km
4.on scene care 10 CPR
5.care in transit : SBAR SOAP
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Situation, background, assessment, recommendation

case trauma background : MIVT
(mechanism,injury,vital,treatment ; )
anatomical , 30kg/hr ; criteria trauma
center( )
6.transfer to : at ER - MI CAG , stroke center, trauma center
definite care
**The Rod of Asclepius : Ancient Greek symbol of healing

Ambulance 3 (ALS , ILS intermediate , BLS) + FRfirst response unit( )

Resource deployment( )
- Fixed deployment - static location
- Dynamic deployment - basic life/ incidence

EMS training : EMR(responder), EMT(technician), Advanced EMT, Paramedic, ENP(nurse)

Medical oversight
- direct : supervise cover field, consult (online medical direction)
- indirect : guideline protocol/step esp. life threatening
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Hazardous material incident

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Syncope
5 Key : transient loss of consciousness(T-LOC) 20 , fall,rapid onset,short duration,spontaneous recovery
cerebral blood flow (transient global cerebral hypoperfusion)

Prevalence : Bimodal age 10-30 yr parasymp / = Neuro reflex

>70 yr symp = orthostatic hypotension

Approach Trauma Cerebral concussion DAI(diffuse axonal injury)

AOC
Non Trauma Syncope , epilepsy, hypoglycemia
Non-syncopal syncope cerebral hypoperfusion

: disorder without any LOC

>> DDx : fall, cataplexy(
conscious ) , psychogenic pseudo-syncope ,
TIA of carotid origin
: disorder with partial or complete LOC seizure, trauma, psychogenic()

>> DDx : metabolic(hypogly hypoxia hyperven), epilepsy, intoxication ,

vertebra-basilaer TIA( postr circulation)

Movement Trigger
Syncope Short tonic clonic prodrome : Short duration of
N/V, headlightnededness, cold, sweat, abd symptom <1min
discomfort, blur [vagus n. GI ]
Seizure Prolong tonic clonic Aura Prolong confusion
atonic
Coarse rhythmic synchronous
** partial seizure complex partial seizure = syncope
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pre Post Urinary Tongue

incontinence bite
Syncope tip Muscle
pain/headache
> CPK
2
Seizure Pre-ictal : Todd weak seizure
syncope

Cause of syncope

1. Neuro reflex (most common) cough/micturition syncope

- Neuro-cardiogeninc Tilt(tilt table test) > VR > BP > catechol >

reflex vagal afferent to brainstem > vagal efferent > HR

> sym withdraw > vasodilate syncope
block catechol ; tx
2. Orthostatic hypotension
3. Cardiac cause concept >>
2.1 Anatomical/Machanical
obstruct flow(AS, MS), Pump fail,

cardiac temponade( EDV>SV), Aortic dissect( false tract )

3.2 Arrhythmia

History

PE : ?? cause Neuro/cardio R/O non-syncope

>> Postural V/S(orthostatic hypotension), Neuro sign( recover100%), carotid bruit( obstruction),
arrhythmia, murmur(AS,MS)
LAB : 12-lead EKG, 24hr ambulatory monitor(Holter), Head-up Tilt table testing( reflex syncope),
 PiP BM19 25

Classification
1. Neurally Parasymp overtone > BP drop SVR
mediated syncope
: 500ml> preload > symp >
carotid > parasymp ( cardio advice 555) > bradycardia
3 : carotid, 1.1 Carotid syncope : /
vasovagal, vagovagal
1.2 vasovagal : emotional stress[fear, pain, blood phobia]
syncope
1.3 situation syncope : vagovagal syncope[vagus nerve] : cough/sneeze, micturition,
postprandial, post exercise
2. Orthostatic Symp tone
hypotension(OH)
OH chronically impaired vasoconstrict(symp ) esp. beta block/diuretic,

Standing - BP fall, syncope OH-abnormal decreased in SBP upon standing =
ortho > 3 ** reflex syncope
: 1 hypovolume 2 drug antiHT alcohol diuretic antipsychotic
3 (2nd autonomic failure) DM uremia SCI amyloidosis 4neuro
3. Cardiac syncope Arrhythmia
- Brady : sick sinus cardiac output escape rhythm
!! " "
- Brady : AV block : 3rd P/QRS > P QRS polymorphic
Neuro
VT (TdP) cardio

Arrhythmia - Tachy >150 >> filling time low flow MI
ex. AS HOCM,
arrhythmia Structure : LV , PE syncope then PE

Key question : LOC, T, spon ?? High risk for CVS risk ??

Ix (tilt table, holter, ... )
supine > cardio
Sanfrancisco syncope rule = Syncope high risk serious outcome D/C
: E C H E S S CHF, Hct<30%, EKG abnormal, shortness of breath, SBP<90mmHg + Elyte
= 3 Lab CXR, CBC, EKG
Severe anemia > run MI HypoK > run TdP

3 condition syncope D/C !!

Short term high risk criteria which require prompt hospitalization or intensive evaluation
1. severe structural/CAD : CHF, LVEF, previous MI
2. important co-morbid : severe anemia, Electrolyte imbalance
3. clinical suggest arrhythmic syncope
: syncope during exertion/supine, palpitation at time syncope, FHx of SCD,
EKG suggest arrhythmic syncope
: non-sustained VT,
: Bifascicular block(LBBB or RBBB with Lt ant/post fascicular block, or other intraventricular conduction
abnormalities with QRS >120ms),
: Prolong/short QT, RBBB with STE in V1-3(Brugada pattern)
: TWI in Rt precordial leads, epsilon waves, ventricular rate suggest ARVC
 PiP BM19 26

Precordial ECG leads of a 44-year-old woman during regular sinus rhythm,

with an epsilon wave (arrow) in leads V1-V3 (major criterion),
right precordial QRS prolongation >110 msec (major criterion),
and T-wave inversion in leads V1-V3 (minor criterion).

Management
High risk, recurrent syncope >> consult cardio echo/...
Low risk > ADVICE
1. Reflex syncope Pharmaco therapy ** reflex syncope !!
: beta block(), SSRI, Theophylline, Scolopamine,...

PCMs(physical counter pressure maneuver) ( afterload )

(
OH syncope )
preload 500ml
Syncope () > PCMs
= Tilt training ( parasymp )
: tilt table ( )
2. OH syncope tx volume
Fludrocortisone
PCMs
stocking

Off label : > vasoconstrict

reflex > PCM , tilt training

OH > hydration** , , , unstress volume
Cardiac > manage ACLS, consult cardio
 PiP BM19 27

Geriatic medicine
Mx : PT, improve nutrition

1. Fall ** Fall : melena, U/D(dementia, old CVA, MDD), , ADL(
), 4 alcohol/sedative, antiHT(orthostatic), SSRI antidepress, antipsychotic
Key safety discharge - [ ] Fall > PM&R
- [ ] Get up and go test 3
- [ ] hypotension if <100 aware
2 Delirium : acute change mental status, fructuation, confusion, disorganized thinking
Type : Hyperactive, hypoactive( Dx , ass with sepsis/infect), mixed type MM, dementia **>50%
at ER miss emergency/
At ER Screen by bCAM(brief confusion assessment method) for delirium
level conscious
intention
disorganized thinking : ? ? 12 ? ?
Mx : I WATCH DEATH
, control pain, O2, orientate
2 cardiac - collapse syncope
2 confusion - dementia, delirium, AOC
3 AUR constipation
4 poly drug >3
5 older abuse, geriatic trauma
Breathing prone Hypoxia, hypercarbia, infection; prone respi fail tube
Heart Catechol response > HR PE : orthostatic, gait/balance, neuro
> film CXR **

4hrPTA
Problem list : partial to GTC seizure 4hrPTA, Lt hemiparesis, Status epilepticus
Significant alcohol drinking, last 1wk
U/D : organic hallucination

>> lesion : Rt hemisphere

DDx emer : Intracranial seizure : Stroke - hemorrhagic, chronic SDH
Status dystonicus - conscious , withdraw Baclofen intrathecal type
; = spinal seizure( conscious )
Alcohol withdrawal seizure : (symp overtone),
Ophistotonus DDx Epidural abscess !!
 PiP BM19 28

Toxicology

Toxidrome
Depressed 1. Opiate MO, codeine Triad : CNS depress + Miosis + respi depress(RR<12)
Opioid
2. Sedative/hypnotic V/S stable, arousable, RR , pupil normal, no coma
- BZD, Phenobarb, Ethanol,
GHB = , drug rape,
Chloral hydrate, GHB(GABA)
Mech GABA R : GHB > GABAA :
> GABAB : inhibit GABA(autoregulation)
relatively GABA + Tx BZD
Stimulate/agitate Sympathomimetic BP/PR/temp, , , pupil ,
Ex. Cocaine, metamphet, pseudoephedrine, bath salt(street
drug dx amphet), MDMA( > Hallu)
Antichol S/S
1. 2. Bowel hypoactive 3. Bladder dysfunction(UR, full)
**AntiHis
**Buscopan(scopolamine hypoactive bowel )
Cholinergic Ops carbamate

> secretion obstruct
[ crep N/V/D urination abd pain]
Toluene > hydrocarbon

heart sensitize : > Cardiac arrest sudden sniffing death syndrome SSDS
Procodyl(Codeine) Pepsi Tramol ; , serotonin syndrome

Serotonin syndrome criteria

1. 5-HT : MAOI, SSRI, Dextromethophan, Meperidine ; drug interaction
2. autonomic symptom : tachycardia( post-ictal), diarrhea, , tremor
38 , agitation
Phenytoin TB , myoclonic seizure
3. Clonus : inducible >> spontaneous(significant)
Valproic level therapeutic 50-100
hyperreflex , Clonus >2beat( , DTR 3-4+)
3+ = Clonus ; Lithium, Dilantin 4+ = clonus

- Valproate toxic > hyper NH3 Valproic level NH3

Antidote = L-carnitine NH3 met mitochondria

: TCA EKG prolong QT, tall R V1, wide QRS

repeat EKG
1st sign antichol : pupil : opioid
Arousable : BZD/phenobarb
TCA overdose Mx observe ER 6hr time peak TCA
HCO3 push block EKG change
Then drip HCO3 redistribution
= 5%DW + 3amp drip rate 1.5-2x of maintenance rate
pH keep 7.55 alkalosis > arrhythmia
 PiP BM19 29

, <6

M/C , household product( -HCl, conc<15%),

poisonous plant(- burn)

- atropine, antichol(buscopan)
/ - digoxin > arrhythmia

Risk : family factor - > antiHTN,antiDM

unsafe storage <2m,

childhood behavior 4-5 nicotine > arrest

Prevention 1. Education - , , Create awareness

2. Modify environment
3. Legislative intervention() - poison prevention packaging act(PPPA)

: <5
= CRP(child resistant packaging) / child proof

Basic Toxic approach

1. Medical A , carbamate > secretion suct
assessment
Protect C spine injury
ABC + DEFG
B = wide AG met acido
C BP,coma cocktail[glucose, thiamine, naloxone, O2] ; try push
D Dx/Decon
E Enhance elimination
F Find antidote
G Get consult
2. History Who ; Paracet toxic 10x = 150mg/kg
5W What (paracet + antichol ; gastric emptying

When decontamination 2-3
NG larvage within 1hr, act charcoal 2hr in paracet, paracet single dose(or
8hr) plot normogram 4hr , 5
Where route exposure, geographic location - tramol,
Why >6 consult psychi( )
History /
, environment, occupation , drug[household, medication]
Ex. CT brain edema, anemia, basophilic poisoning
= Lead encephalopathy : , IQ Lead level
 PiP BM19 30

PE V/S, mental status

toxicology / () Antichol + Bowel bladdder absent
handshake
( BP shoot >> Antichol / symp mimetic )
Skin - Cellular asphyxia : CO, CN, H2S ; burn silk/plastic
lactate>10 antidote CN
- metHb O2 , chocolate
Pupil - pinpoint(<1mm) : opioid(synthetic), opiate
DDx : pontine hemorrhage, chol(OPs), alpha blocker(/),
clonidine/tizanidine(cental alpha2 block opioid )
- : symp, antichol
GI/GU Bowel/bladder fn hypoactive bowel sound, full bladder/retention > antichol
Refle/tremor - , ankle clonus positive(DTX4+=) = block 5HT
: SSRI "serotonin syndrome"
Skin
1. Cyanosis hypoxia, metHb(ferric 3+ Hb ) ; oxidizing agent(Dapsone)

>> industrial gas(N2 ,benzocaine)

; Hb Fe2+ ferrous O2 > metHb

; bedside O2 10-20

blood color test "chocolate blood"

Antidote : methylene blue in metHb >30 reduce Fe3+ ; >10

1. Cyanide cyanosis CO poisoning

"ETS O2 O2 venous "

bedside eye ground retinal vein/artery , cherry red skin - classic

Cellular asphyxia - CO CN H2S( ) ; H2S knock down phenomenon

 PiP BM19 31

BP HR RR Temp Pupil Skin GI/GU

Symp Wet, sweat
Antichol BP shoot +/- Dry No bowel
sound, UR
Chol +/- +/- Wet
Opioid Dry
Sedative- Dry
hypnotic

Substance
1 Opioid 2/3 coma/miosis/respi depress( RR shallow )
>> pupil opioid tube !!!
Naloxone 0.04mg/1amp > double q 3-5 min V/S stable ( withdraw) ; tube
Then drip 2/3 dose mg/hr
Observe 2-3 hr
2 Symp BZD x , no ceiling effect max 120 mg
NTG BP shoot ; Beta block BP ( alpja )
IV fluid
3 Sedative BP drop arousable, no pinpoint, sat drop = BZD
BZD/Phenobarb/ethanol >300mg/dl /GHB/Chloral hydrate ; GHB = rape
; co-ingestion (alcohol, TCA QT prolong)
Mx : observe Neuro/Respi, Antichol symp, IV fluid
4 Antichol , pupil , BP shoot , same sympathetic
Block muscarinic : central = confusion , agitate, tremor, hallu, myoclonus
Peripheral = mydriasis, anhidrosis, tachycardia, UR/ileus
BZD agitate, physostigmine
5 Chol OP, carbamate , sarin gas , Alzheimer : Rivastigmine
V/S Ach presynaptic symp/parasymp
[early BP shoot, late BP drop, HR ]
> V/S shoot secretion ; symp

>> : + fasciculation (NMJ - Ach )

muscarinic SLUDGE + Killer 3Bs nicotinic 5 : MTW(TH)F
( killer 3B = bronchorrhea/spasm/bradycardia) mydriasis/tachycardia/weak/hypertension/fasciculation
Atropine 1.8-3mg(3-5amp) , double dose dry secretion, then 1/10 dose drip /hr
2-PAM/Palidoxime 30mg/kg bolus, drip 8mg/kg/hr ; OPs carbamate rev
Diazepam

Diagnostic Lab
: E'lyte AG - wide osmolal gap : glycol ethanol ... Drug level phenytoin , salicylate level for HD
ABG, serum osm, renal/liver function
 PiP BM19 32

Met acidosis A CAT MUD PILES ; Wide AG > Osmolar Gap

Acetaminophen 30g : early stage met acid
- hugh dose
block mito > lactic acidosis ; 24hr
CN, CO Cellular asphyxia
Alcohol ketoacidosis chronic abuse B1
glucose DKA
Toluene acute inhalation > Hippuric acid ; chronic normal AG acidosis = distal
RTA hypoK prox m weak
Methanol, > MALA(Metformin ass with lactic acidosis) chronic use, acute
metformin
20g >> SLED
Uremia
DKA
Propylene glycol
INH, Feinhibit mito > INH induce seizure pyridoxal enzyme GABA
GTC , antidote : B6 5g or 70mg/kg
Lactate
Ethylene glycol > toxic alcohol , glycolic acid, oxalic acid urine crystal
Salicylate - ASA, methylsalicylate 555
- Mix respi alkalosis( medulla) + wide AG met acido ; acidemia

toxic alcohol - methanol, ethylene glycol level

Wide AG > Osmolar Gap

Osmolar gap = measure Osm( ) Calculated Osm

; normal <10
Ethanol

Osmolar gap >10 Methanol Ethanol Diuretic/mannitol Isopropyl alc Ethylene glycol
1 wide AG Alc freezing point
=methanol ethanol
ME DIE Toxic Alc
wide AG

PK Absorption Distribution Metabolism Elimination

Intoxication Mx Decontamination Antidote Enhanced elimination
 PiP BM19 33

Decontamination absorption
: Skin decon remove clothes, wash scalp/no rubbing 15min injury
- EYE wash free flow
GI decon - induce emesis , life threatening larvage

- 3 : Gastric larvarge, AC, WBI

> 1) NG larvage within 1hr
> 2) Act charcoal <1hr, paracet <2-4hr - activated capsule

- SDAC L: single dose 1g/kg, aspirate

- CI : CHAMPS = Corrosive Hydrocarbon Alcohol

MW > heavy Metal(AS Fe) Pb
Salt(Na Li Mg K decon WBI ; )
> charcoal WBI

> 3) WBI - PEG solution 1-2L/hr ( 25-50ml/kg/h) via NG 4-6hr

not absorb by AC[CHAMPS] : heavy metal, Li, SR/XR coat product, body packer

** Sx , battery consult ENT for scope( burn)

Antidote HD, Toxic alcohol HD

CCB/Beta block antidote : Insulin CCB/BB block Ca ch, Beta receptor insulin >
!! HIE
HIE : keep K 2.5-2.8 off K shift ; case arrest ( K8)
keep K ( 4)
+ Mg/PO4
: 20% IV fat emulsion 1.5ml/kg LBW ( sink theory) (CCB, BB - propranolol)
Conservative : Vasopressor
- Levophed max 20g/kg/min ; titrate dose TPR > HF ; Epi ( heart,vessel)
 PiP BM19 34

Enhance elimination

1. MDAC - 0.5-1 g/kg/q 4 hr interrupt Enterohepatic circulation "Gut dialysis"

CI bowel sound/ileus , aspirate

Indication Those people drink Charcoal quickly

theophylline Phenobarb dapsone CBZ(tegretol), quinine
Phenytoin

2. Urine alkalinize HCO3 keep pH 7.5-8 "ion trap"

100% reabsorb
; Tumor lysis syndrome uric

salicylate , (2,4D) herbicide

Dose : IV HCO3 3 amp drip > urine pH ; K/Elyte

3.Drug hemodialysis 1) MW 2) low protein binding

3) low volume of distribution <1( ) ex. Li ; TCA Vd

STUMBLE : Salicylate, Theophylline, Urea, Methanol, Barbiturate, Lithium, Ethylene glycol

Common intox PED

1.Paracetamol : Stage 1 N/V 3 liver dysfunction 3-4

2 coag prolong 4 recovery comp

Predict : level > plot normogram 4hr , or . <150mg/kg, 7.5g

Antidote : IV 150-50-100
> 150mg/kg load over 60min, then 50mg/kg over 4hrs, then 100mg/kg over 16hours

Case : 150 = Urgent ABCDE 3 6 chronic alcohol

1st Mx : resus/ABCDE
Risk assessment : History - 5W co ingestion (
>6 )
PE - V/S stable co ingestion Everybody lies
Amlodipine
toxidrome : 1 minute toxico: mental / pupil / skin handshake / bowel sound bladder full / reflex tremor
Pb : Acute paracetamol overdose with prior Hx use of alcohol drinking
Suicidal attempt
Mx : GI decontamination[NG,activated charcoal] : role 1-2hr
NAG oral/IV hepatic failure/enceph IV
symptomatic tx ; ER
Lab : basic lab, LFT, coag, paracet level,
- Lactate( liver failure liver transplant ; large overdose para
 PiP BM19 35

mitochondria > ETS fail anaerobic )

- Creatinine
Para half life 4hr , overdose level >10g or 200mg/kg within 8hr
Nomogram : 4hr 150mcg/ml 300 hepatotoxicity
Key NAG : level 8hr 8hr
8hr / Tx !! >8hr MM
: Aim : drip rate <10mcg/ml = negative or liver enz <1000x2 off INR !! <2
Mx : level 2 half life liver function

Bactrian = double hump - delay gastric emptying time(antichol, opioid)
peak drug level 2 level

2.Salicylate , Pylorospasm > delay absorption, Vd

early - N/V , diaphoresis, Vertigo, hearing loss, temp uncoupling oxidative phosphorylation
- Mix respi alkalosis( medulla) + wide AG met acido

- acidemia
- Mx : Gastric decon SDAC, MDAC, WBI

3.Fe intox , ANC

: 20-60mg/kg mild toxic , >60

- Pathophysio : overwhelm transferrin > GI CVS mito, coagulopathy, gastritis > perforate
- clinical : N/V/D, hemorrhagic gastritis
- 2-5d
multisystem organ failure
- 4-6wk fibrosis

- Tx : Iron chelator - deferoxamine Red vin rose

 PiP BM19 36

EKG with Toxico life threatening

1.wide QRS tall R in aVR Na ch block wide QRS + tachy + = Cocaine
>100msec(toxico) >3mm or R:S >0.7 TCA wide QRS + tachy + (antichol)
antiarrhythmic = TCA
- Ia(quinidine/procainamide) brady antiarrhythmic
- Ic(flecainide) > K quinidine
K Ic

2.QT prolong K block E P A B A - TCA, SSRI, FQ/Mac, Motilium Mg TdP

(450 460) K HCO3 Mx : K/Mg +
K shift > QT prolong !! prolong QT

3.ST elevation Cocaine, Amphet dx cocaine

cocaine STEMI
sympathomimetic induced MI : Beta blocker
catechol > alpha vasospasm > MI cocaine Alpha
, BP shoot **

Substance /
substance EKG TCA, amphet, SSRI, Theophylline( )
GTC = Strychnine , Tetanus /progression
conscious S > toxin 24-48hr , +valium24-48hr
T > - ,
: Spatula test post pharynx , sense 90%
valium laryngospasm
Lactate perfusion 2-2.5 , prove shock lactate clearance ( 20% 2hr)
Ophistotonus DDx Epidural abscess !!
Rhabdomyolysis : P , CK, lactate, UA blood
Opiate : heroin morphine codeine met morphine
Opioid meperidine, tramol, fentanyl

= silica gel

DDx emer : Intracranial seizure

: Stroke - hemorrhagic, chronic SDH
Status dystonicus - conscious , withdraw Baclofen intrathecal type ; = spinal seizure(
conscious )

Alcohol withdrawal seizure : (symp overtone),

 PiP BM19 37

Forensic Toxicology
3 : 1. Alcohol,
2. ( BZD,TCA)

3. : CO2 CN

: , , , , ,

: (level) screen +ve > spec test "..."

- Screening(color test , immunoassay - EMIT,FPIA)

- Spec(chromatography- TLC GC HPLC) Dx screen Dx

Chromatography gas = GC
3 : Femoral, Basilar , Jugular

1. Alcohol
: . 2522 2537( )
.
( .378 )
.378
- : Breathalyzer / / GC ; /

1. (BrAC) Alc

Henry law( )
blood : breath ratio(B:Br ratio) = 2,000 : 1

x2,000 BAC = BrAC x 2,000 BAC

, , , > / . ,
= ()
2. tube antiseptic alcohol NaF - preservative

, ferment Alc bact

Breathalyzer Interfere by acetone Simple, rapid, reliable
GC (blood, urine, ) High selective High reliable , specialist
 PiP BM19 38

- BAC >50g/dL = co-ordination (finger to nose, ataxia )

( )
Alcohol : abosorb at duodenum (1hr 60% )
- zero order kinetic 0.015 men| 0.018 g/dL women

/
4-7 10-12 10-15 28-40 40-50

- : .

1. = BAC (metabolize 20g/dL q 1 hr)

5.00 . 6.00 . 7.00 . 8.00 .

BAC 6.00 . 50g/dL >> = 70g/dL

2. BAC () no metabolism

3. Alc bact ferment >

>> Marker : n-Propanol

- : /

2. : Amphet, Opiate, /

7
1 Amphet
2 Morphine codeine opioid
3 2
4 BZD
5

1. - ,
() Heroin >> 6-MAM
Opioid ( morphine 7 BBB)
-MO/Heroin/Codeine met MO
(MO , Heroin )
2. Metamphet(MA) - Metamphet
Amphet MDMA - 10 10 , 99% ( )
MDA
>> (symp MD = A =
) >> Club drug
3. Mitragynine Opioid R - ,
Kratom
,
 PiP BM19 39

4. tetrahydrocannabinol (THC) Vd Hf
opioid / >
urine

30
>>

Body packer syndrome

Club drug ( ),
( > ketamine
Bath salt +

4x100 CNS (sedate, euphoria) ; ,

> /
= 3 100 = , /
Dextro( non opioid)/Codeine(opioid )
+/- /( pyrethoid ) 555

Nimetazepam (ER )
(Erimin 5) BDZ five five happy5

- : specimen
> ( for Dx, ) ; 48 hr

>

> ( - 1-3 1 /
1 ) //
1. Screen : 60-80% Color test

Immunoassay Strip/cassette : /
amphet OH
+ FP (Codeine , AntiHis/Pseudoephedrine ,
Phentermine/Fenfluramine )

>> 2. GC/MS(mass spectrometer)

Positive urine drug finding ** 48 hr

Metamphetamine Morphine/Codeine , Cocaine Cannabinoid
positive 1 g/ml 0.3 g/ml 50 ng/ml
3. BZD , TCA
: Aprazolam(Xanax), Lorazepam(Ativan), Midazolam(Dormicum), Diazepam(Valium), Flunitrazepam(Rohypnol)
 PiP BM19 40

4.
Insectiside OP : irrev thion phos Mevinphos, Parathion
( solvent), = = ()
ON(nitrogen) - carbamate : rev Methomyl/LannateR
> ( solvent OP)
chlorinated hydrocarbon DDT()
Pyrethroid , thrin Pyrethrin, Cypermethrin( )
/
Rodenticide Zinc phosphide > gas toxic
Coumarin / ()
10 > bleed 2-3 /
Arsenic > A S N : anemia(DIC) , skin cancer, nasal inflame to pulm edema
> short Hf in blood >> //( Cocaine) >
Herbicide Paraquat quat xone Gramoxone
react with O2 to form ROS > free radical damage >>> Liver / Kidney / Lung(DAD)
,
Color test

: NaHCO3 + Na dithionate 1:1 W/W + urine specimen >> Positive Blue
Glycosate : ,

Toxic gas CO carboxyHb - ,
,
, /
> cherry red coloration of skin , edema(brain, pulmonary), cardiotoxicity
CN /,
(apple peach plum apricot cherry) ( > CN )
- 1
H2S mech CN >
( nerve ending ) >
 PiP BM19 41

- Dx
: >> Lannate(Carbamate - Methomyl)

>> Paraquat( )
- Cocaine (
)
mech inhibit uptake catechol
hydrolysis (Hf )
> metabolite Benzoylecgonine
- OP : Ach Nicotinic R > pupil constrict opioid /hyperactive BS(parasym over) ; Mx

Tx : Atropine +|- pralidoxime(2PAM) antagonist AchE bond irrev

ON : Carbamate : AchE-I rev (spontaneously hydrolyzed) ; OP irrev PO43- 3 bond

rev > less CNS toxic, no long term sequelae, Tx with atropine

alcohol met 20/hr(zero order)

morphine heroin > metabolize
- + /

(Alc>400 )