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Emergency Med Exam 4 > Approach to poisonings and ingestions > Flashcards

Approach to poisonings and ingestions Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Types of exposure

A

● Ingestion
● Inhalation/ Insufflation
● Skin or mucous membrane
● Injection

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2
Q

Priorities in managing the poisoned patient

A

● Resuscitation
○ Cardiac Arrhythmias
○ Mechanical Airway Support
○ Fluids
○ Seizures (Tx w/ Benzodiazepine)
● Elimination techniques (eg. Activated
Charcoal)
● Decontamination (eg.Chemical spills,
Organophosphates)

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3
Q

Complications in the poisoned patient

A

● Antidote- substance is known
● Hypoglycemia (Tx w/ IV Dextrose)
● Hyperthermia (eg. Sympathomimetics)
● Hypothermia (eg. Opioids)
● Keep your differential diagnosis broad

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4
Q

Toxicology- History

A

● Poor Historian
○ Children, altered mental status, elderly, confusion, agitation
● Family, EMS, medical records
● Ask about suicidal ideation
● Medication history
● Ask about when, what, route, amount, intent

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5
Q

Decontamination procedure

A
  • Use PPE
  • Decontamination areas, Remove clothing
  • Eyes- copious irrigation, Alkali worse than acids
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6
Q

Gastric Decontamination

A
  • Emesis- ipecac syrup has a limited role
  • Orogastric Lavage- limited role, first hour or massive dose
  • Activated Charcoal
  • Whole bowel Irrigation- use Polyethylene glycol
  • Urinary Alkalinization
  • Hemodialysis- very specific criteria
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7
Q

Activated Charcoal use:

A
  • < 1 hour from ingestion
  • Substances known to be absorbed by the charcoal
  • 1-2 gm/kg (max 100 gm)
  • Vomiting and aspiration is a concern
  • Patients don’t like it
  • Charcoal binds to toxins, limiting absorption
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8
Q

Urinary Alkalinization

A
  • Prevents resorption of acidotic drugs
  • Salicylate toxicity, Phenobarbital, Herbicides
  • Correct hypokalemia
  • Sodium Bicarbonate bolus, monitor urine pH
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9
Q

Discharge consideration

A
  • Poison control
  • Substance, Amount, Timing, Extended release
    medication?
  • Admit observation?
  • Abuse or neglect?
  • Mental health evaluation?
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10
Q

MUDPILES

A

M- Methanol
M- Metformin
U- Uremia
D- Diabetic (or Alcoholic) Ketoacidosis
P- Paraldehyde
P- Propylene Glycol
I- Isoniazid
I- Iron
L- Lactic Acidosis
E- Ethylene Glycol
S- Salicylates

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11
Q

What is a Toxidrome?

A

Substances belonging to a particular
pharmaceutical/chemical class often
produce a cluster of symptoms and signs,
or “toxidrome”,enabling the identification
of potential toxins when a clear history is
unavailable

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12
Q

Anticholinergic toxidrome class substances

A
  • Diphenhydramine is the most common for overdose
    Atropine, Tricyclic antidepressants, Phenothiazines,
    Antihistamines, Antiparkinsonian drugs, Jimsonweed (Abused for
    hallucinogenic effects), Belladonna (Taiwan)
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13
Q

Anticholinergic toxicity

A
  • Dry, flushed skin, dry mucous membranes, mydriasis, urinary retention, decreased bowel sounds, altered mental status
  • Confused, agitated, hyperthermia, wide-complex tachyarrhythmias secondary to sodium channel blocking.
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14
Q

Anticholinergic fatalities

A

secondary to severe agitation, status epilepticus,
hyperthermia, wide-complex tachyarrhythmias, and cardiovascular
collapse

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15
Q

Anticholinergic toxicology treatment

A

● Observation
● Monitor temperature
● Activated charcoal is < 1 hour
● Pharmacologic sedation w/ Benzodiazepine
● Sodium Bicarbonate for wide complex tachycardia.
● Consider Physostigmine when purely anticholinergic

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16
Q

Sympathomimetics substances

A

Cocaine, Amphetamines, Cathinones “Bath Salts” , MDMA
● Inhaled, ingested, IV

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17
Q

Cocaine mechanism

A
  • Blockade of the presynaptic reuptake of
    norepinephrine, dopamine and serotonin
  • Excess neurotransmitter results in sympathetic
    activation.
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18
Q

Sympathomimetic clinical featuers

A

● Agitation, Mydriasis, Tachycardia, Hypertension,
Diaphoresis, Seizures, Hyperthermia
Vasoconstrictive
● Hypertension
● Ischemia bowel. Miscarriages
Psychoactive
Pulmonary

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19
Q

Amphetamines

A

Several prescription drugs in this category.
Methamphetamine
Methylphenidate (Ritalin)
Dextroamphetamine (Dexedrine)
Ephedrine (Ephedra)
● Enhance the release and block reuptake of catecholamines.
Drugs of abuse
● Down regulation of dopamine receptors over long-term use.

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20
Q

Amphetamines clinical features

A

● Agitation, Mydriasis, Tachycardia, Hypertension,
Diaphoresis, Seizures, Hyperthermia,
Rhabdomyolysis
● Intracranial hemorrhage, infarction,
encephalopathy,
● Seizures
● Paranoid psychosis
● Advanced tooth decay

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21
Q

Sympathomimetics management

A
  • CBC, CMP, Creatine kinase, EKG, cardiac marker,
    PT, PTT, Head CT
  • Urine Drug Screen- Some Rx meds can be
    positive
  • IV access
  • Monitor Vitals
  • Supportive care, O2 prn
  • Treat hyperthermia- Cool mist fans, sedation
  • Seizures and sedation ( Tx w/ Benzo)
  • CCB and nitroglycerin for ST segment changes
    and SVT
  • Body packers at risk for large dose toxicity and
    death
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22
Q

Cholinergic substances

A
  • Organophosphates
  • Nerve Agents
  • Acetylcholinesterase inhibitors- Pyridostigmine
  • Wild mushrooms
  • GI irritation
  • CNS effects
  • Muscarinic symptoms
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23
Q

Organophosphates

A

Group of Insecticides - Varying brand names - Neurotoxicity- Inhibits Acetylcholinesterase - Irreversibly (aging) - Chemical spills
Nerve agents are organophosphate based - Sarin, VX

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24
Q

Organophosphates exposure

A
  • Inhaled
  • Skin, Mucus membrane, Eyes
  • GI exposure
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25
Q

Organophosphates clinical features

A
  • Dose dependant
  • Route of exposure
  • Chronic Exposure does occur
  • Cholinergic effects
  • Nicotinic effects
  • Miosis, muscle fasciculations, paralysis
    Sx range from mild to severe
  • HA, nausea, lacrimation, rhinorrhea, salivation
  • Confusion, coma, seizures, respiratory failure, death
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26
Q

Organophosphates diagnosis

A
  • History and toxidrome
  • Cholinesterase levels take time
  • Don’t delay care
27
Q

Organophosphates treatment

A
  • PPE and protect the caregivers
  • Decontamination
  • Respiratory support, Oxygen
  • Atropine repeat q5 min until dry secretions
  • Pralidoxime given prior to “aging” reactivates enzyme
28
Q

Opioid clinical features

A
  • Respiratory and mental depression
  • Miosis - not always
  • Orthostatic hypotension
  • Nausea vomiting
  • Urticaria- Histamine release
  • Bronchospasm
  • Decreased GI motility and urinary retention
  • Seizures with tramadol
  • Acute Lung Injury
29
Q

Opioids management

A
  • Drug Screen-
  • Not specific
  • Beware of tylenol combos
  • Protect the airway
  • Naloxone an Opioid competitive antagonist
  • Given IV, SC, IM
  • Dose of 0.1mg - 2.0 mg IV depending on status
  • Activated Charcoal
  • Observe in the ED for 4-6 hours after last naloxone dose
  • Admit for continuous monitoring (eg. Buprenorphine)
  • Continuous infusion for long acting opioids (eg. Methadone)
30
Q

Alcohol Withdrawal

A
  • Alcoholic Ketoacidosis-
  • Tremors/ Hallucination
  • Withdrawal seizures- Tx w/ benzodiazepine (GABAergic)
  • Delirium Tremens: Confusion, tachycardia, hypertension
31
Q

Benzodiazepine Withdrawal

A
  • Occur after abrupt discontinuation (Sx up to 7-10 days later)
  • Similar to Alcohol
  • Anxiety, insomnia, tremors, anorexia, confusion, seizures
  • Long taper with D/C
32
Q

Cocaine withdrawl

A
  • Irritability, paranoid ideation, depression
33
Q

Methamphetamine withdrawl

A
  • Drowsiness, lethargy, hunger, tremor, chills, depression, suicide
34
Q

Opioid withdrawl

A
  • Typically not life threatening
  • Diaphoresis, tremors, irritability, insomnia
  • Clonidine, antiemetics
  • Methadone, Buprenorphine once withdrawal symptoms appear
35
Q

Toxic alcohols

A

Methanol and Ethylene Glycol

36
Q

Twice as potent as Ethanol and thus considered
highly toxic

A

Isopropanol

37
Q

Ethanol

A

● Clinical inebriation
● Legally intoxicated at 80 mg/dL
● Death can occur 400-500 mg/dL in non-habitual users
○ Respiratory depression and coma
● Broken down by alcohol dehydrogenase

38
Q

Work-up Ethanol

A

● Keep your DDx broad for altered mental status
● Bedside glucose
● Check Ethanol levels
● Drugs of abuse
● CBC, CMP - gapping metabolic acidosis likely not from ethanol

39
Q

Treatment for ethanol exposure

A

● Observation
● Activated charcoal doesn’t work
● Hypoglycemia
● Supportive

40
Q

Isopropanol

A

more toxic than ethanol
● CNS depression
● Gastric irritation
● Respiratory depression, hypotension, and coma
● Also metabolized by alcohol dehydrogenase
● Toxic dose at 1 mL/kg
● Children are highly susceptible to toxic doses

41
Q

Dx of isopropanol exposure

A
  • Ketonuria without acidosis, smell of rubbing alcohol on breath
42
Q

Tx for isopropanol

A

Supportive, watch for GI bleed, and consider hemodialysis

43
Q

Methanol

A
  • Highly toxic metabolites
  • Windshield fluid, automotive cleaning products, solvents, fuel for stoves, and contaminated alcohol beverages.
  • Lethal dose at 1.25 mL/kg
  • Permanent visual changes at 30mL
  • Metabolized by alcohol dehydrogenase → Formic acid
  • Formic acid is the toxic metabolite→ Metabolic acidosis & End Organ damage
  • Seizures, respiratory failure, pancreatitis, visual damage, tachypnea
44
Q

Ethylene Glycol

A
  • Highly toxic metabolites
  • Hydraulic fluid, antifreeze. Contaminated alcohol beverages
  • Has a sweet taste, so kids or pets may accidentally ingest
  • Lethal dose in adults is 1.0 - 1.5 mL/kg
  • Metabolized by alcohol dehydrogenase → Glycolic acid
  • Glycolic acid is the toxic metabolite→ Metabolic acidosis & End
    Organ damage
  • CNS depressant, metabolic acidosis, renal failure
  • Urine check may show calcium oxalate crystals
45
Q

Methanol and Ethylene Glycol

A
  • Blood ethanol level
  • Measure methanol and ethylene glycol levels
  • Calculate osmolar gap
  • ABG
  • CMP
  • Creatinine kinase
  • Ketone levels
  • Lactate levels
  • Consider acetaminophen and salicylate levels
46
Q

Methanol and Ethylene Glycol
Treatment

A
  • Cardiovascular support
  • Correct acidosis
  • Sodium Bicarbonate to maintain pH
  • Block metabolism
  • IV Fomepizole, IV Ethanol
  • Increase clearance
  • Hemodialysis (Used when severe of refractory)
  • Vitamin Therapy
    Disposition
  • Patient likely will need admission
47
Q

Benzodiazepine exposure presentation

A
  • Gamma- aminobutyric acid (GABA) receptor
  • Given IV, IM, PO, PR (Diazepam rectal gel)
  • Half life varys
  • Often occurs as a mixed overdose
  • Sedation
  • Dizziness, somnolence
  • Slurred speech, ataxia, coma
  • Urine drug screen
48
Q

Benzodiazepine exposure treatment

A
  • Death is rare
  • Activated charcoal if early
  • Respiratory support
  • Flumazenil
  • Benzodiazepine antagonist
  • Caution w/ chronic user of benzodiazepine
  • Contraindicated in intracranial pressure
    increase eg. Head Trauma, Mass effect
49
Q

Salicylate substances

A
  • Aspirin
  • Can be enteric coated
  • Pepto Bismol
  • Aspercreme- topical
  • Oil of Wintergreen
50
Q

Salicylate toxicity

A

Toxicity is complex
- As pH ↑more salicylate crosses cell membrane
- ↑ brain salicylate concentration
- Respiratory alkalosis followed by anion gap metabolic acidosis
- Corrosive injury to the GI tract

51
Q

Salicylate clinical features

A
  • Dose, Age dependent
  • Chronic exposures often worse
  • Tachypnea, tinnitus, hearing loss, fever
  • Confusion, coma, seizures, cerebral edema
52
Q

Salicylate work up

A
  • Labs with salicylate level
  • Level is unreliable indication of toxicity
53
Q

Salicylate management

A
  • Supportive
  • Activated Charcoal
  • Reducing salicylate concentration
  • Urinary alkalinization- Target urine pH 7.5
  • IV Fluids with Sodium Bicarbonate
  • K is added to prevent hypokalemia
  • Also keeps salicylate away from the brain
  • Hemodialysis for severe toxicity or refractory
54
Q

Antipsychotics substances

A
  • Risperidone (Risperdal)
  • Haloperidol (Haldol)
  • Phenothiazines
  • Prochlorperazine (Compazine)
  • Promethazine (Phenergan)
55
Q

Antipsychotics toxicity

A
  • D2 receptor blockade
  • Blockade in the nigrostriatal region → extrapyramidal Sx
  • Worse with typical high potency
56
Q

Neuroleptic Malignant Syndrome

A
  • New drug or dosage change-
    Often acute
  • Tetrad
  • Fever
  • Altered
  • Muscle rigidity
  • Autonomic dysfunction
57
Q

Neuroleptic Malignant Syndrome management

A

Discontinue the drug
Supportive- Temp control, sedation, intubation
Bromocriptine- dopamine agonist
Dantrolene- muscle relaxant

58
Q

Iron toxicity

A
  • GI vs systemic toxicity is dose dependant
  • GI irritant
  • Widespread organ injury
  • toxic free radicals
  • Metabolic Acidosis
  • increased lactate
59
Q

Iron clinical features

A
  • Vomiting
  • Correlates to toxicity, also hematemesis
  • Lactic Acidosis
  • Coagulopathy
  • Hepatic failure
60
Q

Iron toxicity treatment

A
  • Activated Charcoal doesn’t work
  • Whole bowel irrigation
  • Endoscopy can remove tablets
  • Deferoxamine- binds to iron and allows renal excretion
61
Q

Lead toxicity treatment

A
  • Chelation therapy
  • Dimercaprol (caution with peanut allergy) and Edetate Calcium Disodium
62
Q

Acetaminophen toxicity

A
  • Glutathione is
    maxed out
  • Increased NAPQI
    which is toxic
  • Worse with ETOH
63
Q

Acetaminophen treatment

A
  • N-Acetylcysteine substitutes for
    glutathione
  • Activated Charcoal

Emergency Med Exam 4 (5 decks)

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