Approach to poisoned pt, toxidromes, labs

Question 1

A patient presents to the ER with an odor on their person and is altered. Upon receiving a call from the ER, the CSPI knows the following smells are common with certain drugs or toxins. Which one is incorrectly paired with their toxin?
A) Garlic odor – arsenic and organophosphates
B) Rotten eggs – disulfiram and mercaptans
C) Wild onions – hemlock
D) Bitter almonds – cyanide
E) Freshly mown hay – phosgene

Answer 1

Answer C: Wild carrots, parsnips, and turnips smell like water hemlock (diacetylenic acid). All the rest are correct.

Cicutoxin occurs in any part of the plant and is the most common form of lethal plant ingestion. Symptoms include N/V/abd pain within 15 mins and then presents like a cholinergic toxidrome with diaphoresis, excess salivation, bradycardic, hypotensive, bronchial secretions, eventual respiratory distress and cyanosis and ultimately seizures

Question 2

What mothball is radiopaque?

Answer 2

Paradichlorobenzene

Question 3

Several drugs cause tinnitus: diuretics, lead/mercury, cisplatin, and aminoglycosides, among others. Only a few drugs consistently cause tinnitus at toxic doses. One of those is salicylates, what is another?

Answer 3

salicylates and QUININE as being 2 agents who consistently cause tinnitus at toxic ranges. Also you could see tinnitus with high doses, but not toxic doses, of caffeine.

Question 4

This 39yo male presents to the ER with an odd muscle spasm in his neck causing his head to be turned to the side and protrusion of his tongue. He doesn’t remember what his medications are but he takes 5 of them, with the last one just started 2 weeks ago. Based on the symptoms he is having, what do you anticipate the treatment to include?
A) Baclofen and vicodin
B) Stop the offending agent
C) Labs and IV fluids/hydration
D) Diphenhydramine or benztropine

Answer 4

Answer D. This is a dystonic reaction and the general consensus is giving diphenhydramine or benztropine to resolve the symptoms and block the acetylcholine release.

Question 5

Knowing that some toxins, like barium and iron, are radiopaque, which substance below is not?
A) Buckshot and other tasty bullets
B) Enteric-coated preparations, like ASA
C) Iodine and potassium
D) A carefully well-packed heroin drug mule
E) Sustained-released preparations

Answer 5

Answer D). All of the substances are radiopaque with the exception of the well packed heroin drug mule. The packets themselves are not radiopaque, but some of the air that gets trapped (no matter how careful they are packed) in the swallowed drugs and it shows up on x ray and can be detected, especially if many are ingested since it presents as a pattern.

Question 6

When a patient with a Benadryl/poly drug overdose presents as anticholinergic in the ER, BP 151/98, HR 130, RR 26, agitated with mild hallucinations, and QRS 102 msec, what is the best option for treatment?
A) Cyproheptadine
B) Physostigmine
C) Benzodiazepines
D) Ketamine

Answer 6

Answer C. Physostigmine and benzos are the only ones that make sense. Since it is a poly drug overdose and QRS 102, then stay away from Physostigmine (possible that TCA might be ingested as well). Physostigmine has been used for helping to relieve drug induced delirium when a suspected anticholinergic is on board. It is effective but ultimately lasts for about 1 hour before wearing off and the delirium returns. There are many things to consider before, during and after it is administered and is not thought to outweigh the risks. Since the drug is known that is causing the delirium, it is best to treat with benzos.

Question 7

What is cause of metal fume fever?

Answer 7

Occurs from inhaling galvanized/heated metals – usually zinc oxide
Does not occur from sensitization – not an allergy

Question 8

Metal fume fever sxs?

Answer 8

Influenza like: fever, chills, cough, fatigue, thirst, abd pain

Question 9

What’s Monday morning fever?

Answer 9

The exposure tolerance is lost over the weekend and when returning to work sxs redevelop

Question 10

Metal Fume Fever Treatment?

Answer 10

Sxs usually resolve over 24-36 hrs and are self limiting

Supportive care and maybe wear a respirator while working?

Question 11

What is the difference between metal fume fever and polymer fume fever?

Answer 11

Polymers are the cause and are related to thermal breakdown and inhalation
A common cause is the burning/scorching of Teflon pans
This differs from irritant gas exposures with development of a fever and NL CXR

Question 12

Which is the most important to monitor when using atropine to treat a patient with cholinergic poisoning?
A) Blood pressure
B) Heart rate
C) Respiratory rate
D) Temperature
E Level of consciousness

Answer 12

Answer: C. The end point in anticholinergic treatment is clearing and drying of the secretions from the bronchi. Although tachycardia is not a contraindication to continued treatment, it is usually a good marker of success. Persistent tachycardia may suggest inadequate therapy or hypoxia.

Question 13

Which is likely to cause hypotension and tachycardia in overdose?
        A. Clonidine
	B. Digoxin
	C. Morphine
	D. Nifedipine
	E. Nadalol

Answer 13

Answer D. Clonidine initially causes hypertension before a persistent hypotension, but tachycardia is unlikely. The others cause bradycardia in overdose. Nifedipine causes hypotension and tachycardia due to peripheral vasodilation.

Question 14

Which clinical situation is a patient’s LOC normal?
	A) Adreneric overdose
	B) Anticholinergic overdose
	C) Opioid overdose
	D) Opioid withdrawal
	E) ETOH withdrawal

Answer 14

Answer: D. Adrenergic, anticholinergic and opioid overdose all cause altered LOC. Opioid withdrawal causes normal LOC but anxious. ETOH withdrawal causes altered LOC and szs.

Question 15

Which drug is associated with life-threatening hyperthermia?
	A. Arsenic
	B. Botulism
	C. Carbamazapine
	D. Mercury
	E. PCP

Answer 15

Answer E. Carbamazapine is associated with hypothermia. The others are not associated with temperature issues. PCP causes increased temperature, increased HR, BP and RR, agitation, CNS stimulation, dissociative behaviors (like walking on broken legs and not feeling pain).

Question 16

Which symptoms are expected to occur with methemoglobin level of 15% in an otherwise healthy patient?
	A. SOB at rest
	B. Cyanosis
	C. Dizziness and fatigue
	D. Coma or asystole	
	E. Headache or confusion

Answer 16

Answer B. Patients generally tolerate methemoglobin levels of 15% quite well and exhibit a mild cyanosis. However, preexisting disease (anemia, pneumonia, CV disease) may make this level of methemoglobin clinically stressful.

Question 17

Which is most reliably detected by comprehensive tox screen?
	A. Digoxin
	B. Diphenhydramine
	C. Iron
	D. Lithium
	E. Methanol

Answer 17

Answer: B. Comprehensive tox screens typically have problems detecting xenobiotics (XB) present at very low concentrations (digoxin), ionic XB, which are not extracted into organic solvents (iron and lithium); and volatile compounds, which are lost during evaporation of the organic extract (methanol).

Question 18

Which statement about toxicology testing is correct?

A)Confirmation of a + UDS confirms the diagnosis of poisoning
B) False + results are more common than false – results
C) GC-MS should always be used if available
D) Immunoassays can provide both high sensitivity and specificity
E) Use of tox screens frequently improves the outcomes in overdoses

Answer 18

Answer D: Immunoassays have the sensitivity to detect NANOmolar quantities (like digoxin) and also show excellent specificity when directed toward a specific XB, rather than a XB class. Confirmation of + tox screen confirms presence of a drug but does not establish clinical toxicity. False + are typically 0-10% and false – are 10-30%. GC-MS are slow, expensive and over-kill tox screens and rarely effect MGMT with no change in outcome.

Question 19

Propylene glycol is metabolized hepatically by ETOH dehydrogenase to what?
A) Propylethylene glycol
B) Ethylene glycol
C) Lactate
D) Methanol
E) Oxalate

Answer 19

Answer C. Once propylene glycol is metabolized to lactate, it is then broken down to pyruvate and then Co2 and water. Lactic or metabolic acidosis can occur with overdose or excessive dosing.

Propylene glycol is a common diluent for IV medications like Ativan. We recently had a pt get ~118mg Ativan to control ETOH withdrawal in a very short space of time (4hr). This person did develop metabolic acidosis but was delayed in presentation (12 hrs) so not thought to be related.

Question 20

Acute renal failure from adulterated APAP has been associated with which pharmacologic additive?
	A) Diethylene glycol
	B) Polyethylene glycol
	C) Benzyl alcohol
	D) Propylene glycol
	E) Sorbitol

Answer 20

Answer A. So, even if you had no idea about this answer – you could consider that diethylene glycol is similar to ethylene glycol (EG) and is part of our policy of toxic alcohols. It is brake fluid. We know that EG causes renal toxicity and can be reasonably sure than renal toxicity would occur for diethylene glycol. There is no oxalate crystals formed as with EG toxicity, but renal failure does occur.

Polyethylene glycol (PEG or whole bowel irrigation) and sorbitol give you the runs, but don’t shut down your plumbing. Propylene glycol, as already discussed, is an IV diluent and would not be an ideal adulterant for APAP in the PO form. Benzyl ETOH is also a liquid and also not ideal for PO meds.

Question 21

Which is TRUE of eye irrigation after chemical exposures?
A) Use of a Morgan lens should be avoided
B) Outcome is poor if water is used instead of commercially available solutions
C) Regardless of exposure, eye irrigation should continue for 2 hrs
D) Measurement of conjunctival pH may be an unreliable indicator of adequate irrigation
E) Prolonged irrigation is important after severe alkali burns but not severe acid burns

Answer 21

Answer D. Limitations of paper strips, contamination of irrigation fluids and failure of conjunctival pH to reflect the anterior chamber pH are among the reasons that normal pH should be a necessary but not all encompassing endpoint for eye irrigations.

Question 22

A 52 yo female presents to the ER with AG (24) metabolic acidosis and is found to have an osmolar gap of 15. Which is most likely the diagnosis?
A) Methanol intoxication
B) ETOH ketoacidosis
C) Lactic acidosis
D) Renal failure
E) All of the above

Answer 22

Answer E. All of the above. If it were methanol - it is probable that she presented early in her intoxication and we are only seeing this one snapshot in time of labs. You could do another set of labs after hydration and if it were methanol intoxication, then the osmolar gap and metabolic acidosis would be more pronounced. If it were ETOH ketoacidosis and lactic acidosis – those would improve with fluids (and other therapies). If it were renal failure and you gave fluids – you probably were not paying attention to the initial set of BUN/creat (oops ) and they would need a life preserver or dialysis.

Question 23

Which is the greatest prognostic significance in hypothermia?
A) Temperature 70-80F
B) K+ > 10
C) Frostbite
D) Unconsciousness
E) ETOH intoxication

Answer 23

Answer B. Prolonged cardiopulmonary arrest and absolute temperature do not predict poor outcome. Profound hyperkalemia is associated with the inability to successfully resuscitate severely hypothermic patients.