Lightning (Perling)

• Multiple Mechanisms of Strikes (Direct, Ground Current *most common*, Side Splash, Conduction, Streamer)
• Cardiopulmonary Effects- Cardiac Arrest: Asystole, paralysis of medullary respiratory centers
  • Spontaneous ROSC can occur, but will not be breathing spontaneous

• Neurologic Effects- Keraunoparalysis (compartment syndrome mimic), Intracranial hemorrhage, cerebral edema, seizure 
• Dermatologic Effects-lichtenberg figures, burns of varying severity, flashover/linear burn
• Eye/Ear Effects- pupillary dilation/anisocoria, perforated TM, cataracts, transient deafness
• Orthopedic Effects- Rhabdo possible, Compartment syndrome vs keraunoparalysis, posterior shoulder dislocation (lightbulb sign), spinal fractures
• Pregnant Effects- abruptio placentae
• Management: Reverse Triage Mass Casualty- Cardiac Arrest->ACLS immediately. Have higher survival rate, ROSC before breathing, apneic patients need assisted breathing. Cease efforts if no ROSC after 20-30 minutes. 
• Discharge- normal vitals, appears well, no other injuries
• Admit essentially everyone else, likely will require tele monitoring 
• Obtain CT imaging to rule out internal hemorrhage, as lighting can affect similar to blunt trauma
• What To Do: Get in a Car, go inside a deep cave, Go deep into a forest. Isolated Trees are bad. Go to Ravine if in the mountains. 

Toxic Mushrooms (Webb)

• mushrooms are closer to humans than plants genetically (trust me bro)
• 7500 ingestions annually, 3 deaths per year
• Typically Acute gastroenteritis, usually less than 3 hours post ingestion
• Cholinergic toxicity, disulfiram-like reaction, hallucinations, Liver/Nephrotoxicity
• Death Cap Mushroom-Amanita phalloides
  • 90% of mushroom associated deaths, moratlity rate 10-20%
  • Amatoxin, delayed toxidrome (6-12 hours)
  • Nausea vomiting diarrhea-> latent period (24-48 hours) ->fulminant liver failure
  • Tx: Silibinin (IV milk thistle) possible use, but evidence is weak 

Peds Toxicology (Graff)

• Blood brain barrier- more permeable to toxic substances until around 4 months
• Based on mg/kg for most ingestions
• Metabolism is your best antidote, Most declare themselves within 4-6 hours
• No hard contraindication to naloxone
• Charcoal- 1gm/kg, minimizes absorption, contraindications: caustic, typically within 2 hours
• Syrup of Ipecac- Not recommended
• One Pill can kill- CCB, SSRI, Lomotil, Opiates, Salicylates, Camphor, Antimalarials more
• Lomotil- can present like opiate toxicity: narcan and supportive care
• Iron: top cause of death in toddlers, 4 hour iron level, GI decontamination, IVF, deferoxamine IV
  • Remember stages of iron overdose including hepatic failure and delayed gastric outlet obstruction/pyloric stenosis

• Tylenol- check ASA too, charcoal, level 4 hours, Days 1-4 increased LFTs, liver failure, Tx: NAC ideally within 8 hours but still give after 8 hours
• Salicylates: Fever, N/V, tinnitus, seizures, metabolic acidosis, resp alkalosis.  Charcoal, alkalinize urine
• Drano- airway concern, liquefactive necrosis. Vomiting drooling stridor, supportive care, NO ipecac or gastric lavage
• Methanol- windshield washer fluid. Fomepizole, dialysis. CNS depression, HA, met acidosis
• Ethylene Glycol- antifreeze, CNS dysfunction
• Isopropyl- rubbing alcohol. ketones in urine, no fomepizole.
• Anticholinergic toxicity- think atropine. Sleepy then increased CNS symptoms, seizures GTC.  tx physostigmine, GI decon
• Organophosphates- SLUDGE, decontaminate patients. Lots of atropine, pralidoxime. 
• Hydrocarbons- gasoline, cleaners, polishes, risk is aspiration, obs 4-6 hours. Dc asymptomatic
• Sulfonylurea- profound hypoglycemia without response. D50 Octreotide,
• BP Meds- CCB typically hyperglycemia, BB typically hypo/normoglycemia: Tx – calcium, glucagon, insulin and dextrose, intralipid
• Benadryl- anticholinergic. disorientation/delirium, dry mouth, blurred vision Tx supportive care
• Opiates- remember some don’t come back + on drug screen, Heroin found in cbd gummies in community right now
• Bath salts: stimulants, aggressive, hallucinations, panic attacks, agitated “Cloud 9”, rhabdo. 
• CHEMICal Camp mnemonic
• Review Toxic Syndromes

Salicylates (Adams)

• MOA: analgesia, antiinflammatory, antipyretic. Works on COX1 enzyme, inhibits prostaglandins
• Absorption 30min-1hr, 2-4 hours in overdose. 
• Can form bezoar with enteric coated formulation
• Toxicity: >30 mg/dl
• Direct CNS stimulation. Directly stimulates respiratory drive  in medulla= resp alkalosis
• Decreased pH= increased non nonionized ASA= increased crossing BBB= increased CNS ASA
• Neuronal energy depletion -> neuronal apoptosis, neuroglycopenia -> seizures/ CNS symptoms
• Clinical Presentation: CNS: AMS, Seizures, coma, Resp: tachypneic resp alkalosis, Metabolic: hyperthermic, hypokalemic, AGMA, GI: nausea, vomiting, diarrhea, Tinnitus Effects
• Classic: Primary Met Acidosis with Primary Resp Alkalosis. Determine if decrease in CO2 is compensation or if there is another primary acid base disturbance
• Tachypnea is not an indication for intubation. AVOID INTUBATION IF POSSIBLE
  • Give 1-2 mEq/kg bolus of bicarb peri-intubation, awake intubation, Vent settings to match minute ventilation pre-intubation to prevent resp acidosis. High rate and volumes needed (Rate 30, 8 cc/kg example). 

• External and Internal Decon- remove any topical source like Bengay cream. Role of Charcoal depending on mental status. 
• Treatments: Sodium Bicarb
  • Dosing: Bolus 1-2mEq/kg. Maintenance: 3 amps in 1 L D5W, 150-200 ml/hr  maintenance rate
  • Goal serum pH 7.5-7.55, Goal Urine pH 7.5-8.0

• Treatment endpoints: ASA level below 30 x2. 
• Chronic Intoxications typically overlooked. Oil of Wintergreen is highly concentrated and potentially fatal.