A 6-year-old boy is brought to the emergency department 12 hours after ingesting multiple pills. The patient complains of noise in both his ears for the past 10 hours. The patient’s vital signs are as follows: pulse rate, 136/min; respirations, 39/min; and blood pressure, 108/72 mm Hg. The physical examination reveals diaphoresis. The serum laboratory parameters are as follows: Na+ 136 mEq/L Cl- 99 mEq/L Arterial blood gas analysis under room air indicates the following results: pH 7.39 PaCO2 25 mm HG HCO3- 15 mEq/L Which of the following is the most appropriate first step in the management of this patient?

Gastrointestinal decontamination

Multiple-dose activated charcoal

A 55-year-old man presents to the emergency department with hematemesis that started 1 hour ago but has subsided. His past medical history is significant for cirrhosis with known esophageal varices which have been previously banded. His temperature is 97.5°F (36.4°C), blood pressure is 114/64 mmHg, pulse is 130/min, respirations are 12/min, and oxygen saturation is 98% on room air. During the patient's physical exam, he begins vomiting again and his heart rate increases with a worsening blood pressure. He develops mental status changes and on exam he opens his eyes and flexes his arms only to sternal rub and is muttering incoherent words. Which of the following is the most appropriate next step in management?

IV fluids and fresh frozen plasma

A 27-year-old man is witnessed falling off his bicycle. The patient rode his bicycle into a curb and hit his face against a rail. The patient did not lose consciousness and is ambulatory at the scene. There is blood in the patient's mouth and one of the patient's teeth is found on the sidewalk. The patient is transferred to the local emergency department. Which of the following is the best method to transport this patient's tooth?

Wrapped in gauze soaked in normal saline

A 29-year-old woman, gravida 1, para 0, at 33 weeks' gestation comes to her doctor for a routine visit. Her pregnancy has been uncomplicated. She has systemic lupus erythematosus and has had no flares during her pregnancy. She does not smoke cigarettes, drink alcohol, or use illicit drugs. Current medications include iron, vitamin supplements, and hydroxychloroquine. Her temperature is 37.2°C (98.9°F), pulse is 70/min, respirations are 17/min, and blood pressure is 134/70 mm Hg. She appears well. Physical examination shows no abnormalities. Ultrasound demonstrates fetal rhythmic breathing for > 30 seconds, amniotic fluid with deepest vertical pocket of 1 cm, one distinct fetal body movement over 30 minutes, and no episodes of extremity extension over 30 minutes. Nonstress test is reactive and reassuring. Which of the following is the next best step in management?

Administer corticosteroids and continue close monitoring

Discontinue hydroxychloroquine and continue close monitoring

Reassurance with expectant management

Toxicologic emergencies for USMLE Step 2 CK: High-Yield Pediatrics Lessons

General Management - First-Response Playbook

A, B, C, D, E: Airway, Breathing, Circulation, Disability (GCS, pupils), Exposure.
Decontamination: Prevent absorption. Key is timing.
- Activated Charcoal: 1 g/kg within 1 hour. Does not bind all toxins. 📌 PHAILS: Pesticides, Hydrocarbons, Acids/alkalis, Iron, Lithium, Solvents.
- Gastric Lavage: Only for life-threatening ingestions within 1 hour. Contraindicated in corrosive/hydrocarbon poisoning.
Enhanced Elimination: Hasten removal.
- Alkaline Diuresis: For salicylates, phenobarbital.
- Hemodialysis: For severe poisoning (e.g., methanol, salicylates, lithium).

⭐ For any unknown poisoning with altered sensorium, consider the empiric "coma cocktail": IV Dextrose, Naloxone, and Thiamine after securing ABCs.

Toxidromes - Poisoning Pattern Hunt

Recognizing toxidromes (toxicological syndromes) is key to identifying the poison class. Focus on vitals, pupils, and skin findings.

Toxidrome	Vitals (HR, BP, T)	Pupils	Skin	Other	Examples
Anticholinergic	↑	Mydriasis	Hot, flushed, dry	↓ Bowel sounds, urinary retention	Atropa belladonna, Datura, TCAs
Cholinergic	↓ (Musc) / ↑ (Nic)	Miosis	Diaphoretic	↑ Secretions (SLUDGE)	Organophosphates, Carbamates
Opioid	↓	Miosis (pinpoint)	Cool	↓ RR, ↓ Bowel sounds	Morphine, Heroin, Fentanyl
Sympathomimetic	↑	Mydriasis	Diaphoretic	Agitation, seizures	Cocaine, Amphetamines
Sedative-Hypnotic	↓	Normal/Miosis	Normal	↓ LOC, ↓ RR	Benzodiazepines, Barbiturates

⭐ Differentiating Sympathomimetic vs. Anticholinergic: Both cause tachycardia, hypertension, and mydriasis. The key is the skin: Sympathomimetics are sweaty, while Anticholinergics are dry ("hot as a hare, dry as a bone").

Toxidrome Patterns: Vital Signs, Pupils, Skin, Mental Status

Key Poisonings & Antidotes - Villains vs Heroes

Common Antidotes for Pediatric Toxicologic Emergencies

Poison (Villain)	Key Features / Toxidrome	Antidote (Hero)
Organophosphates	Cholinergic: DUMBELS	Atropine + Pralidoxime (PAM)
Paracetamol (PCM)	Hepatic necrosis (late)	N-acetylcysteine (NAC)
Iron	GI bleed, metabolic acidosis	Deferoxamine
Datura	Anticholinergic: "Hot as a hare..."	Physostigmine
Opioids	↓CNS/Resp, pinpoint pupils	Naloxone
Benzodiazepines	Sedation, normal vitals	Flumazenil
Cyanide	Bitter almond breath	Hydroxocobalamin / Nitrites + Thiosulfate

⭐ The Rumack-Matthew nomogram guides N-acetylcysteine (NAC) therapy in paracetamol poisoning. It's plotted from 4 hours post-ingestion; NAC is most effective if given within 8 hours.

High‑Yield Points - ⚡ Biggest Takeaways

Organophosphate poisoning is treated with atropine and pralidoxime; atropine doesn't correct muscle weakness.

For paracetamol toxicity, use the Rumack-Matthew nomogram to guide N-acetylcysteine administration.

Iron poisoning is managed with deferoxamine, which causes a characteristic vin-rose colored urine.

Salicylate toxicity presents with respiratory alkalosis then metabolic acidosis; treat with urinary alkalinization.

The classic opioid toxicity triad is pinpoint pupils, respiratory depression, and coma; reverse with naloxone.

For TCA overdose, QRS widening is a critical ECG finding, managed with sodium bicarbonate.

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