WikEM - User contributions [en]

Digoxin toxicity

2012-11-14T00:25:09Z

Epae: /* Risk Factors */

== Background ==
*Mechanism of action
**Positive inotropic effect
***Inhibits Na-K pump -> incr extracelluar K, incr intracellular Na -> incr intracellular Ca
**Increases vagal tone
***Can lead to bradyarrhythmias (esp in young)
**Increases automaticity
***Can lead to tachyarrhythmias (esp in elderly)
*Renally cleared
*Hemodialysis does not work

=== Risk Factors ===

#Electrolyte Imbalance
##[[Hypokalemia|Hyperkalemia]], [[Hypomagnesemia]], [[Hypercalcemia]]
#Hypovolemia
#Renal insufficiency
#[[Cardiac Ischemia]]
#[[Hypothyroidism]]
#Meds
##CCBs, amiodarone

== Clinical Manifestations ==
===Cardiac===
#[[Syncope]]
#Dysrhythmias
##PVCs
##[[Bradycardia]]
##SVT w/ AV block
##Junctional escape
##Ventricular dysrhythmia, including bidirectional V-tach (esp in chronic toxicity)
#Digitalis Effect (seen with therapeutic levels; not indicative of toxicity)
##T wave changes (flattening or inversion)
##QT interval shortening
##Scooped ST segments with depression in lateral leads
##Increased U-wave amplitude

===GI===
#Often the earliest manifestation of toxicity
##[[Nausea/vomiting]]
##[[Abdominal Pain]]

===Neuro===
#[[Confusion]]
#[[Weakness]]
#Visual disturbances
##Yellow halos
##Scotomas
#Delirium

==Work-Up==
#Dig level
##Only useful prior to administration of [[Fab]] (otherwise becomes falsely elevated)
#Chemistry
#Urine output
#ECG (serial)

== Diagnosis ==
#Must use H&P and labs in combination; no single element excludes or confirms the dx
#Digoxin level
##Normal = 0.5-2 ng/mL (ideal = 0.7-1.1)
###May have toxicity even with "therapeutic" levels (esp w/ chronic toxicity)
##Measure at least 6hr after acute ingestion (if stable); immediately for chronic ingestion
###If measure before this may be falsely elevated due to incomplete drug distribution
#Potassium level
##Acute toxicity: Degree of [[Hyperkalemia]] correlates w/ degree of toxicity
##Chronic toxicity: K+ may be normal/low (concomitant diuretic use) or high (renal failure)

==DDX==
#CCB/BB toxicity
#Clonidine toxicity
#[[Organophosphate Toxicity]]
#Sick sinus syndrome

== Treatment ==
#'''[[Digoxin Immune Fab]]'''
#[[Activated Charcoal]]
##Questionable efficacy
##Only an adjunctive tx; NOT an alternative to fab fragment therapy
##Consider only if present within 1 hr of ingestion
##1g/kg (max 50g)

===Dysrhythmias===
#[[Digoxin Immune Fab]] is the agent of choice for all dysrhythmias!
#[[Cardioversion]] should only be used as a last resort (may precipitate V-Fib)
##Consider lower energy settings (25-50J)
#Bradyarrhythmias (symptomatic)
##[[Atropine]] 0.5mg IV
##[[Pacing]]
#Ventricular dysrhythmias
##[[Dilantin Load|Phenytoin]]
###Enhances AV conduction
###Phenytoin: 15-20mg/kg at 50mg/min
###Fosphenytoin: 15-20mg PE/kg at 100-150mg/min
##[[Lidocaine]]
###Decreases ventricular automaticity
###1-3mg/kg over several minutes; follow by 1-4mg/min

===[[Hyperkalemia]]===
#Treat with [[Fab]], not with usual meds
##Once Fab is given hyperkalemia will rapidly correct
#If [[Fab]] unavailable and hyperkalemia is life-threatening then treat with:
##Glucose-insulin
##Sodium bicarb
##Kayexelate
##Dialysis
##Calcium (controversial: some say dangerous, others say not)

===[[Hypokalemia]]===
#Chronic intoxication
##Raise level to 3.5-4
#Acute intoxication
##Do not treat (likely that potassium level is rapidly rising)

===[[Hypomagnesemia]]===
#Treat with 1-2g over 10-20 min
##Monitor for resp depresion
##Avoid in pts with:
###Renal failure
###Bradydysrhythmias/conduction blocks

==Disposition==
*Admit for signs of toxicity or history of large ingested dose; admit to ICU if [[Fab]] given
*Discharge after 12hr observation if asymptomatic after accidental overdose

==See Also==
*[[Digoxin Immune Fab]]
*[[Toxidromes]]
*[[Digoxin]]

== Source ==
*Rosen's
*Tintinalli

[[Category:Cards]]
[[Category:Drugs]]
[[Category:Tox]]

Parkinson's disease

2012-11-05T19:58:33Z

Epae:

==Background==
*Extrapyramidal movement disorder a/w reduced dopaminergic receptors in substantia nigra

==Clinical Features==
*TRAP mnemonic:
**Tremor (resting)
***Initially is unilateral tremor of upper extremity, esp finger and thumb ("pill rolling")
***Dissipates when intentional movement is performed
**Rigidity (cogwheel)
***Elicited by causing passive movement of limb through full range of motion
**Akinesia
***Slowness of voluntary movement
**Posture/equilibrium impairment
***Impaired ability to turn or change direction while walking

== Treatmenthttp://www.wikem.org/w/index.php?title=Parkinson%27s_Disease&action=edit&section= ==

*Dopamine agonists 
**Levodopa  +Carbidopa (peripheral decarboxylase inhibitor) = gold standard 
**pramipexole (Mirapex) ropinirole (Requip) 
*Anticholenergics 
**Benztropine 
*Monoamine oxidase inhibitor - blocks DA reuptake 
**selegiline (Eldepryl) 
**rasagiline (Azilect) 

 

==Source==
Tintinalli

[[Category:Neuro]]

Parkinson's disease

2012-11-05T19:51:54Z

Epae:

==Background==
*Extrapyramidal movement disorder a/w reduced dopaminergic receptors in substantia nigra

==Clinical Features==
*TRAP mnemonic:
**Tremor (resting)
***Initially is unilateral tremor of upper extremity, esp finger and thumb ("pill rolling")
***Dissipates when intentional movement is performed
**Rigidity (cogwheel)
***Elicited by causing passive movement of limb through full range of motion
**Akinesia
***Slowness of voluntary movement
**Posture/equilibrium impairment
***Impaired ability to turn or change direction while walking

== Treatmenthttp://www.wikem.org/w/index.php?title=Parkinson%27s_Disease&action=edit&section=3 ==

*Anticholinergics
**Benztropine
*Dopamine agonists
**Levodopa/ Carbidopa 
**pramipexole (Mirapex) ropinirole (Requip) 
*Monoamine oxidase inhibitor - blocks DA reuptake 
**selegiline (Eldepryl) 
**rasagiline (Azilect) 
**Bromocriptine

==Source==
Tintinalli

[[Category:Neuro]]

Parkinson's disease

2012-11-05T19:47:45Z

Epae:

Phenytoin toxicity

2012-11-05T19:43:16Z

Epae:

== Background ==

*Mortality is extremely rare after intentional overdose if good supportive care is provided
*Rapid IV dosing carries greatest risk (due to propylene glycol constituent of IV form --> myocardia depression & cardiac arrest)
*90% protein bound; dialysis ineffective

== Clinical Features ==

*CV (only with IV form)
**Bradycardia
**Hypotension
**Asystole
*Neuro
**Nystagmus
***First only with forced lateral gaze; later becomes spontaneous
***May disappear at higher levels
**Ataxia
**Decreased LOC
*GI
**N/V
*Skin
**tissue infiltration (IV) --> "purple glove syndrome"
**edema, pain, ischemia, tissue necrosis, compartment syndrome

 

==Diagnosis==
*Phenytoin level
**Provides a rough guide only; neither sensitive nor specific
**Level >10: usually no symptoms
**Level 10-20: Occasional mild nystagmus
**Level 20-30: Nystagmus
**Level 30-40: Ataxia, slurred speech, N/V
**Level 40-50: Lethargy, confusion
**Level >50: Coma, seizure (rare)

==Treatment==
#Detoxification
##Activated charcoal PO
#Bradyarrhythmias
##Atropine, pacing
#Hypotension
##IVF

==Disposition==
*Cannot base on phenytoin level (erratic absorption after PO overdose)
**Consider discharge if pt has only mild symptoms and serial phenytoin levels decline

==Source==
Tintinalli

[[Category:Tox]]

Phenytoin toxicity

2012-11-05T19:40:54Z

Epae:

== Background ==

*Mortality is extremely rare after intentional overdose if good supportive care is provided
*Rapid IV dosing carries greatest risk (due to propylene glycol constituent of IV form --> myocardia depression & cardiac arrest)
*90% protein bound; dialysis ineffective

==Clinical Features==
*CV (only with IV form)
**Bradycardia
**Hypotension
**Asystole
*Neuro
**Nystagmus
***First only with forced lateral gaze; later becomes spontaneous
***May disappear at higher levels
**Ataxia
**Decreased LOC
*GI
**N/V

==Diagnosis==
*Phenytoin level
**Provides a rough guide only; neither sensitive nor specific
**Level >10: usually no symptoms
**Level 10-20: Occasional mild nystagmus
**Level 20-30: Nystagmus
**Level 30-40: Ataxia, slurred speech, N/V
**Level 40-50: Lethargy, confusion
**Level >50: Coma, seizure (rare)

==Treatment==
#Detoxification
##Activated charcoal PO
#Bradyarrhythmias
##Atropine, pacing
#Hypotension
##IVF

==Disposition==
*Cannot base on phenytoin level (erratic absorption after PO overdose)
**Consider discharge if pt has only mild symptoms and serial phenytoin levels decline

==Source==
Tintinalli

[[Category:Tox]]

Carbamazepine toxicity

2012-11-05T19:38:06Z

Epae:

==Background==
*Has anticholinergic in addition to antiepileptic effects
*Therapeutic concentration: 4-12

== Clinical Features ==

*May be delayed and follow crescendo-decrescendo course (due to delayed GI motility)
*CNS
**Ataxia
**Nystagmus
**Coma
*Anticholinergic toxidrome
*CV
**Dysrhythmias are rare but may occur
**Widened QRS
**QT prolongation

==Diagnosis==
*Levels do not accurately correlate w/ clinical severity

==Treatrment==
*GI detox
**Activated charcoal (if presents w/in 1hr of ingestion)
*Dialysis is effective (if needed)

==Disposition==
*Consider d/c for pt with decreasing levels (measured few hrs apart) and is asymptomatic

==Source==
*Tintinalli

[[Category:Tox]]

Organophosphate toxicity

2012-11-05T19:24:56Z

Epae: /* Clinical Features */

==Background==
*Irreversibly binds acetylcholinesterase -> cholinergic crisis
*Used as insecticides (malathion) and chemical warfare (sarin, VX)
*Consider in ddx of pt w/ AMS + miotic pupils

==Clinical Features==
#SLUDGE(MM)
##Salivation, lacrimation, urination, diarrhea, GI pain, emesis, miosis, muscle weakness
#Killers B's
##Bradycardia, bronchorrhea, bronchospasm

==Diagnosis==
*CBC
**May show leukocytosis
*Lipase
*LFT
*CXR
**Pulmonary edema in severe cases
*ECG
**Ventricular dysrhytmias, torsades, QT prolongation, AV block

== Treatment ==
#Protection
##Wear protective clothing to prevent secondary poisoning
##Use neoprene or nitrile gloves (not latex)
#Decontamination
##Dispose of all clothes
##Wash pt with soap/water
#Airway
##Suction as needed
##Intubation if needed d/t respiratory secretions / bronchospasm
###Use nondepolarizing agent
#Breathing
##Use O2 100% NRB
#Antidotes
##Atropine
###May require massive dosage (hundreds of milligrams)
###Does not reverse muscle weakness
###Dosing
####Adult: 1mg or more IV; repeat q5min until tracheobronchial secretions attenuate
####Child: 0.01-0.04mg/kg (but never <0.1mg) IV
##Pralidoxime
###Displaces organophosphate from acetylcholinesterase (if given early)
###Dosing
####Adult: 1-2gm IV over 5-10min; continuous infusion of 500mg/hr if no initial response
####Child: 20-40mg/kg (up to 1gm) IV over 5-10min; 5-10mg/kg/hr if no initial response

==Disposition==
*Minimal exposure only requires decon and 6-8hr obs

==See Also==
[[Toxidromes]]

==Source==
*Tintinalli

[[Category:Tox]]

Immune thrombocytopenic purpura

2012-05-13T00:29:38Z

Epae:

==Background==
*Acquired autoimmune disease resulting in destruction of platelets
*Because circulating plts are functional, life-threatening bleeding only once plt <10K
*Types
**Acute
***More common among younger children
***Affects men/women equally
***Resolves in 1-2mo
**Chronic
***Lasts >3mo
***More common in adults and women
***Rarely remits spontaneously or with tx
***More likely to have an ynderlying disease or autoimmune disorder (e.g. SLE)

==Clinical Features==
*Petechiae
*Epistaxis, ginigival bleeding, menorrhagia

==Diagnosis==
*Diagnosis of exclusion
**Must differentiate from chronic ITP, which suggests an underlying disorder
*CBC shows normal cell lines except for the platelets (may have mild anemia)

==Treatment==
=== Options ===

#Corticosteroids
##First-line in adults
##Prednisone 60-100 mg/d w/ taper after count reaches normal
##Methylprednisolone 30mg/kg/d IV x3d (for life-threatening bleeding)
#IVIG
##First-line in children
##1gm/kg/d x2d
#Anti-D (RhoGAM)
##Pt must be Rh+ for it to work
#Transfusion (platelets)
##Indicated for life-threatening bleeding
##Transfuse only following first dose of methylprednisolone or IVIG
###Holding transfusion until after first dose results in greater rise in plt count
#Estrogen (uterine bleeding)
#25mg IV x1              

===Indications===
====Adults====
#Plt >30K and asymptomatic: Usually do not require treatment
#Plt count <30K: Prednisone
#Plt <50K AND bleeding: Prednisone
#Life-threatening bleeding
##IVIG, methylprednisolone, platelet transfusion

====Children====
#Plt count >30K: Usually do not require treatment
#Plt count <20K + significant bleeding: IVIG
#Plt count <10K: IVIG
#Life-threatening bleeding
##IVIG, methylprednisolone, platelet transfusion

==Disposition==
#Admit:
##Pts w/ plt count <20K or those who have significant mucous membrane bleeding
#Discharge:
##Plt counts >20K AND asymptomatic or have only minor petechiae

==Complications==
#Rare; more common in elderly
##Intracerebral bleeding
##Severe GI bleeding

==See Also==
[[ITP in Pregnancy]]

==Source ==
*Tintinalli
*UpToDate

[[Category:Heme/Onc]]

Immune thrombocytopenic purpura

2012-05-13T00:28:50Z

Epae:

==Background==
*Acquired autoimmune disease resulting in destruction of platelets
*Because circulating plts are functional, life-threatening bleeding only once plt <10K
*Types
**Acute
***More common among younger children
***Affects men/women equally
***Resolves in 1-2mo
**Chronic
***Lasts >3mo
***More common in adults and women
***Rarely remits spontaneously or with tx
***More likely to have an ynderlying disease or autoimmune disorder (e.g. SLE)

==Clinical Features==
*Petechiae
*Epistaxis, ginigival bleeding, menorrhagia

==Diagnosis==
*Diagnosis of exclusion
**Must differentiate from chronic ITP, which suggests an underlying disorder
*CBC shows normal cell lines except for the platelets (may have mild anemia)

==Treatment==
=== Options ===

##Corticosteroids
###First-line in adults
###Prednisone 60-100 mg/d w/ taper after count reaches normal
###Methylprednisolone 30mg/kg/d IV x3d (for life-threatening bleeding)
##IVIG
###First-line in children
###1gm/kg/d x2d
##Anti-D (RhoGAM)
###Pt must be Rh+ for it to work
##Transfusion (platelets)
###Indicated for life-threatening bleeding
###Transfuse only following first dose of methylprednisolone or IVIG
####Holding transfusion until after first dose results in greater rise in plt count
##Estrogen (uterine bleeding)
###25mg IV x1

              6.    Emergent splenectomy - uncontrolled/life threatening hemorrhage

                         1. after tranfusion, IVIG, and steroids

===Indications===
====Adults====
#Plt >30K and asymptomatic: Usually do not require treatment
#Plt count <30K: Prednisone
#Plt <50K AND bleeding: Prednisone
#Life-threatening bleeding
##IVIG, methylprednisolone, platelet transfusion

====Children====
#Plt count >30K: Usually do not require treatment
#Plt count <20K + significant bleeding: IVIG
#Plt count <10K: IVIG
#Life-threatening bleeding
##IVIG, methylprednisolone, platelet transfusion

==Disposition==
#Admit:
##Pts w/ plt count <20K or those who have significant mucous membrane bleeding
#Discharge:
##Plt counts >20K AND asymptomatic or have only minor petechiae

==Complications==
#Rare; more common in elderly
##Intracerebral bleeding
##Severe GI bleeding

==See Also==
[[ITP in Pregnancy]]

==Source ==
*Tintinalli
*UpToDate

[[Category:Heme/Onc]]

Pneumonia (main)

2012-05-12T18:04:23Z

Epae: /* Unhealthy */

==Background==
3 questions:
# Does this pt have pneumonia?
# If yes, does this pt need to be admitted?
# If yes, admit to the ward or ICU?

==Clinical Presentation==
*Fever, chills, pleuritic CP, productive cough
**Fever is seen in 80%
*Tachypnea
**Most sensitive sign in elderly
*Abdominal pain, N/V/diarrhea may be seen with Legionella infection

==Work-Up==
#CXR
#CBC
#Chemistry

If pt will be admitted:
# Blood cx (required if pt may require ICU during their course)
# Sputum staining
## If concern for particular organism

==Health care–associated PNA risk factors==
#Pts hospitalized for 2 or more days w/in past 90d
#Nursing home/long-term care residents
#Pts receiving home IV abx
#Dialysis pts
#Pts receiving chronic wound care
#Pts receiving chemotherapy
#Immunocompromised pts

==Pseudomonas risk factors==
# Alcoholism
# Immunosuppression (incl. steroids)
# Structural lung disease
# Malnutrition
# Recent abx
# Recent hospital stay

==Treatment==
===Outpatient, community-acquired PNA===
====Healthy====
#Clarithromycin XL 1000mg PO QD x7d OR
#Azithromycin 500mg PO day 1, 250mg on days 2-5 OR
#Doxycycline 100mg BID x 10-14d (2nd line choice)
==== Unhealthy ====

#Chronic heart, lung, liver, or renal disease; DM, alcholism, malignancy.  Add
##Levofloxacin 750mg QD x5d OR
##Moxifloxacin 400mg QD x7-14d OR
##Amoxicillin-clavulanate 2g BID AND Azithromycin 500mg day 1, 250mg days 2-5 OR Doxy
##3rd generation cephalosporin AND Azithromycin or Doxy

===Inpatient===
====Community-acquired PNA====
#Levofloxacin 750mg QD x5d OR
#Moxifloxacin 400mg QD x7-14d OR
#3rd generation cephalosporin AND azithromycin
====Health Care-associated PNA====
#3-drug regimen recommended
##(Cefepime 1-2gm q8-12h OR ceftazidime 2gm q8h) + cipro 400mg q8h + vanco 15mg/kg q12 OR
##Imipenem 500mg q6hr + cipro 400mg q8hr + vanco 15mg/kg q12 OR
##Piperacillin-tazobactam 4.5gm q6h + cipro 400mg q8h + vanco 15mg/kg q12

====ICU, low risk of pseudomonas====
#Ceftriaxone 1gm IV and Azithromycin 500mg IV OR
#Ceftriaxone 1gm IV and (moxifloxacin 400mg IV or levofloxacin 750mg IV)
#Penicillin allergy
##Moxi/levofloxacin and (aztreonam 1-2gm IV or clindamycin 600mg IV)

====ICU, risk of pseudomonas====
# Cefipime, imipenem, OR piperacillin-tazobactam + IV cipro/levo
# Cefipime, imipenem, OR piperacillin-tazobactam + gent + azithromycin
# Cefipime, imipenem, OR piperacillin-tazobactam + gent + cipro/levo

==Disposition==
See [[Pneumonia (Port Score)]]

==See Also==
*[[Pneumonia (Pathogens)]]
*[[Pneumonia (Peds)]]
*[[Pneumonia (Port Score)]]

==Source==
*UpToDate

[[Category:ID]]
[[Category:Pulm]]

Priapism

2012-05-07T04:49:43Z

Epae:

== Background ==

*Prolonged, unwanted erection not a/w sexual stimulation > 4h 
*May lead to erectile dysfunction and penile necrosis if untreated
*2 types:
**1. High-flow (nonischemic)
***AV fistula from trauma (lacerated cavernous artery shunts blood into cavernous bodies)
***Usually not painful
***Ischemia/impotence does not occur
**2. Low-flow (ischemic)
***Veno-occlusion causing pooling of deoxygenated blood in cavernous tissue
****A/w SCD, meds, trauma, leukemia, infection, spinal cord injury/cauda equin, hypercoag
***Painful
***Fibrotic change --> impotence

== Clinical Features ==

*Erect corpus cavernosum
*Flacid glans and spongiosum

== Work-Up ==

#CBC   (eval leukemia, sickle cell)
#type & screen    (may need to exchange transfuse)
#coags
#urinalysis/tox (etoh, marijuana, cocaine can cause priapism)
#abg from cavernosa (if hx unclear) hypoxic, hypercapneic, acidotic --> low flow
#Ultrasound
##Can distinguish between high-flow and low-flow

== DDx ==

#Peyronie's Disease
#Urethral foreign body
#Penile surgical implant
#Erection from sexual arousal

== Treatment ==

#Morphine
#IV hydration (sickle cell)
#O2 (sickle cell)
#Transfusion (sickle cell)
#Urology consult (especially important with traumatic priapism)
#Aspiration/injection of corpus cavernosum
##Rarely beneficial after 48hr
##Penile nerve block (2 or 10 o'clock) 
##Aspirate 5cc of blood from corpus cavernosum (3 or 9 o'clock position of shaft) w/ 19ga needle
###Inject 1mL diluted phenylephrine (100-500mcg/mL) q3-5min until resolution or one hour (max 1000mcg)

== Disposition ==

#Admit if refractory to treatment
#May dispo home if treatment is successful with close f/u by urology

== Source ==

*Tintinalli
*UpToDate
*emedicine

[[Category:GU]] [[Category:Procedures]]

Carbon monoxide toxicity

2012-04-21T23:35:30Z

Epae:

== Background ==

#Colorless, odorless gas
#Most toxic component in smoke inhalation and major contributor to fire-related deaths
##Can co-occur with [[Cyanide]] toxicity in industrial fires
#Sources
##Automotive exhaust
##Propane-fueled heaters
##Wood or coal-burning heaters
##Structure fires
##Gasoline-powered motors
##Natural gas-powered heaters
#Peak incidence in winter months

== Pathophysiology ==

#Hypoxia
##Binding affinity of Hb for CO (carboxyhemoglobin) is 200x that of O2
##Half-Life
###Room air: ~5hrs
###100% O2: ~1hr
###HBO 2.5atm: 24min
#Lactic acidosis
##CO inhibits oxidative phosphorylation
#Hypotension
##CO induces NO2 and guanylate cyclase release --> vasodilation release

== Workup ==

#VBG
##Co-oximetry analysis will provide carboxyhemoglobin level
#Lactate
#Chemistry
#Troponin
#Total CK (rhabdo)
#ECG
##May range from normal to STEMI (most common ST, then prolonged QT)
###Few of the pts w/ AMI from CO have occlusive lesions in their arteries
#?Head CT
##May show b/l globus pallidus lesions in severe cases

== Clinical Features ==

#May range from "flu-like" symptoms to coma
#CNS
##Headache
##Visual disturbances
##Confusion
##Ataxia
##Seizure
##Syncope
##Retinal hemorrhage
##Focal neurologic deficit
#GI
##Vomiting
#Pulm
##Dyspnea/tachypnea
#Cardio
##Chest pain
##ECG changes/dysrhythmias
#Derm
##Bullous skin lesions
##Classic finding of cherry red oral mucosa is rarely seen in living pts

== Diagnosis ==

#Must have high clinical suspicion (esp in pts w/ coma, AMS, or anion gap acidosis)
##Comatose pt removed from fire should be assumed to have CO poisoning
#Carboxyhemoglobin Level
##Interpretation must take into account time since exposure and O2 tx
##Normal value in non-smokers is ~1%, normal value in smokers may be up to 10%
##Symptoms and COHb levels do not always correlate well
#Pulse oximetry is unreliable
##CoHb registers the same as O2Hb so will have artificially high SpO2
##O2 saturation gap reflects discordance of SpO2 by pulse oximeter vs by VBG

== Treatment ==

#O2 100% by NRB or ETT
##Provide O2 until COHb value <10%
#Hyperbaric Therapy (HBO)
##Decision to initiate HBO should be made in consultation w/ hyperbaric specialist
##Controversial who exactly benefits from tx
##Pt must be stable prior to transport
##Indications (generally accepted guidelines):
###Syncope
###Confusion/AMS
###Seizure
###Coma
###Focal neuro deficit
###Pregnancy w/ CoHb level >15%
###Blood level >25%
###Acute myocardial ischemia

== Disposition ==

#Minimal or no symptoms
##Discharge
#Mildly symptomatic
##Headache, vomiting, elevated COHb level
##Discharge after 4hr obs and symptom resolution
#Severely symptomatic
##Ataxia, syncope, chest pain, neuro deficit, dyspnea, ECG changes, pregnant w/ COHb >15%
##Admit; discuss with hyperbaric specialist

== Source ==

Tintinalli

[[Category:Tox]]