Acute into/ overdose

Question 1

important hx:

Answer 1

• what was taken?
• when?
• how much?
• why?
• anything else taken?

Question 2

Coma cocktail:

Answer 2

• oxygen for hypoxia
• thiamine for wernickes
• narcan for opioids
• glucose for hypoglycemia

Question 3

respiration findings/ meanings:

Answer 3

Respiratory rate
Tachypnea: salicylates
Bradypnea: opioids
Respiratory depth
Hyperpnea: Salicylates (Kussmaul's)
Shallow: Opioids
Temperature
Hyperthermia: Serotonin syndrome, stimulants, anti-cholinergic toxidrome
Hypothermia: Narcotic or sedative-hypnotic

Question 4

pupils meanings:

Answer 4

Size
Large: anticholinergic or sympathomimetic
Small: Cholinergic
Pinpoint: Opioid
Nystagmus horizontal: ethanol, ketamine
Nystagmus rotary or vertical: PCP, some stimulants

Question 5

skin findings and meanings:

Answer 5

Temperature:
Hyperpyrexia: anticholinergic, stimulants, serotonin syndrome, sympathomimetic
Hypothermic: opioids, sedative-hypnotics
Moisture:
Dry: Anticholinergic
Moist: cholinergic
Color – cyanosis, pallor, erythema

Question 6

overall findings and meanings:

Answer 6

Physiologic stimulation: Everything is up
Elevated HR, BP, RR, temp and agitation
Sympathomimetics, anticholinergics, stimulants, hallucinogens
Physiologic depression: Everything down
Depressed temp, HR, BP, RR, lethargy/coma
Cholinergic, opioids, sedatives-hypnotics
Mixed effects: Polysubstance, metabolic poisons, salicylates

Question 7

hemodialysis for:

Answer 7

Salicylates, Methanol, Ethylene glycol, Lithium, Mushrooms, Isopropyl alcohol

Question 8

acetaminophen rules of 150:

Answer 8

Toxic dose = 150 mg/kg single ingestion
Hepatotoxic APAP level at 4 hours 150g/ml
First NAC dose 150 mg/kg
Peak serum levels: 4 hours after overdose

Question 9

stages of Tylenol toxicity:

Answer 9

I (0-24hrs): n/v, but most asymptomatic
II latent stage (24-48hrs): RUQ pain, subclinical increase in AST/ALT/Tbili, INR
III hepatic stage (3-4dys): liver failure, RUQ pain, vomiting, jaundice, coagulopathy, hypoglycemia, renal failure, metabolic acidosis
IV recovery stage (4dys-2wks): resolution of hepatic dysfunction OR death / transplant

Question 10

Tylenol toxicity tx:

Answer 10

NAC (N-Acetylcysteine)
Equal IV and Oral
Loading dose 150 mg/kg
Maintenance 50 mg/kg over 4 hours
Oral = 72 hours
IV = 21 hours

Question 11

NAC indications:

Answer 11

Ingestions with likely or potential toxicity
Late presentations with potential or ongoing toxicity
Chronic overdose with evidence of hepatic damage

Question 12

continue NAC until:

Answer 12

Stop when
APAP undetectable
AST / ALT < 100
AND
INR < 1.5
OR transplant or death

Question 13

when to admit in Tylenol overdose:

Answer 13

Known toxicity / potential toxic levels
Lab evidence of hepatic damage
Unknown time of ingestion and sx consistent with toxicity
Unknown ingestion time with measurable acetaminophen levels.
Intentional self harm

Question 14

salicylates tox:

Answer 14

Weak acid, rapidly absorbed
Enteric coated has delayed absorption
Toxic dose: >150 mg/kg
Lethal dose 480 mg/kg
Mixed respiratory alkalosis-metabolic acidosis
Stimulates respiratory drive causing hyperventilation, but limits ATP production metabolic acidosis
No antidote
Toxicity = rate of absorption > 
rate of elimination

Question 15

salicylate tox presentation:

Answer 15

Early = N/V, tinnitis, diaphoresis, confusion, deafness, tachypnea, vertigo, respiratory alkalosis (direct stimulation)

Late = Anion gap metabolic acidosis, ALOC, pulmonary edema, hypoglycemia (severe), hepatic and renal dysfunction, seizures, death

Question 16

salicylate tox tx:

Answer 16

Empiric dextrose
Activated charcoal
Urinary alkalinization (start if serum level is greater than 35mg/dl)
3 amps bicarbinate in 1 L D5W at 150 ml/hr
Avoid hypokalemia use KCL
Avoid hypoglycemia and pulmonary edema
Q2hour lytes and salicylate levels
Hemodialysis for severe acidemia, volume overload, pulmonary edema, cardiac or renal failure, seizures, coma, levels > 100mg/dl in acute ingestion, or > 60-80 mg/dl in chronic ingestion

Question 17

barbiturate toxic effects:

Answer 17

CNS
Sedation, hypnosis, hypotension, respiratory depression, seizures and death
Pulmonary
Depression of medullary respiratory center leading respiratory depression or collapse
Cardiovascular
Cardiac contractility and vascular tone compromised, hypotension

Question 18

barbiturate exam findings:

Answer 18

Neuro
Lethargy, coma, hypothermia, nystagmus, strabismus, vertigo, ataxia
Psych
Delirium, irritable, aggressive, paranoia
Respiratory
Depression, apnea, hypoxia, ARDS
Cardiovascular
Tachy, brady, hypotension, shock

Question 19

2nd most common overdose:

Answer 19

Isopropanol

Question 20

ethylene glycol overdose:

Answer 20

1-12 hours – CNS depression, vomiting, seizures, coma, tetany
12-24 hours – Cardiopulmonary, hypotension, tachydysrhythmias, ARDS
24-72 hours – Nephrotoxic, oliguria, renal failure, ATN, calcium oxalate crystalluria

Question 21

amphetamine sx:

Answer 21

Increased activity, exhilaration, forced speech, insomnia, irritability, exaggerated reflexes, anorexia, diaphoresis, tachyarrhythmia, chest pain, psychotic-like states, paranoia

Question 22

amphetamine tx:

Answer 22

Charcoal  - because of recycling via enterohepatic circulation
Benzodiazepines
Benzodiazepines
External cooling
Monitoring for cerebral edema

Question 23

opioid od:

Answer 23

CNS depression, lethargy, confusion, coma, respiratory depression, miosis
Pulmonary edema, aspiration, resp arrest
Check for track marks, abscess, rhabdo, compartment syndrome

Question 24

opioid od tx:

Answer 24

Tx Naloxone 0.4 – 2 mg IV/IM/SC
May result in agitation
May need re-dosing
Supportive care
IV fluids

Question 25

pearls:

Answer 25

Always begin with airway, breathing, circulation. The poisoned patient is not exempt from this mantra.
ACLS protocols apply to poisoned patients.
Treat the patient, not the poison. Observe vital signs and provide supportive care constantly.