Approach to the Poisoned Patient

Question 1

key questions about the history when involving toxicology

Answer 1

• time of ingestion
• amount ingested; do a pill count
• liquids; concentration and volume.
• route of exposure
• co-ingestions; did you take the drugs with alcohol?

Question 2

outline a toxicological physical exam

Answer 2

involves all the bodily symptoms

Question 3

Anion gap equation

Answer 3

Na- (Cl and HCO3-)

Question 4

causes of anion gap

Answer 4

MUDPILES

M= methanol, metformin

U= uremia

D= DKA/AKA/SKA

P= paraldhehyde, pyroglutamic acidemia, propylene glycol

I= iron, isoniazid

L= lactate

E= ethylene glycol

S= salicylates

Question 5

Osmolar GAP equation

Answer 5

Calculated OSMOL: 2NA+BUN + glucose + (1.25xethanol)

Osmolar gap= OSM (measured) -OSM (calculated)

Question 6

Ddx osmolar gap (KAMCCPS)

Answer 6

1. toxic alcohols ; methanols, ethylene glycol, isopropanol
2. ketoacidosis/elevated lactate; would see a small elevation osmolar gap
3. mannitol, sorbitol
4. contrast agents
5. CKD
6. pseudohyponatremia
7. Sick cell syndrome

Question 7

ABCDEF toxicology approach

Answer 7

airway, breathing circulation, decontamination, elimation of any other toxin, find an antidote

Question 8

leading cause of acute liver failure– what’s it’s toxic dose?

Answer 8

acetaminophen overdose. 150mg/kg toxic dose.

Question 9

treatment for acetaminophen overdose

Answer 9

NAC; n- acetylcysteine 21 hour protocol.

Question 10

in toxicological exposures, muscle ridigity can be a finding of toxicity. what limbs are more affected?

Answer 10

lower limbs are more likely to be effected.

Question 11

general protocol

1. history
2. ABCDEF and physical exam
3. labs; LFTs, toxic labs like ethanol and acetaminophen levels, CBC, urine analysis.
4. continue ABCDEF when you have more information

Question 12

sick cell syndrome

Answer 12

leaky cells, causing ions and anions and contents leaking out to the environment. causes an abnoraml osmole gap

Question 13

factors to consider when thinking about hemodialysis for poisonin

Answer 13

1. size
2. volume of distribution
3. water/lipid solubility
4. degree of protein binding
5. endogenous clearance.

Question 14

common dialyzable toxins (SMELTV)

Answer 14

S; salicytes

m: methanol

E; ehtylene glycol

L; lithium

T; theophylline

V; valproic acid

Question 15

indications for gastric lavage

Answer 15

pumping patients stomach. for patients who have taken an overdose wehre you think its going to kill them, even with a bunch of pressors. pumping patient stomach will prevent the absorbtion

Question 16

whol bowel irrigation indicatsion

Answer 16

for overdose of extended release medications, or if a bezoir of pills/toxin forms. allows you to flush it out the other end.

Question 17

what is a toxidrone

Answer 17

collection of signs and symptoms associated with exposure to a specific toxin.

Question 18

outline opioid presentation in terms of CNS, pupils, CVS, resp, GI and vital sign symptoms

Answer 18

CNS; drowsy, low LOC

pupils: miosis

CVS: normo/bradycardic, normo/hypotension

resp: low resp rate.

GI; decreased bowel sounds

bital signs; depressed BP and HR, decreased RR, SpO2. decreased temperature

Question 19

there are lots of symptoms that could indicate an opioid overdose presentation. What is the triad toxidrome?

Answer 19

drowsy/low LOC, miosis, and respiratory depression

Question 20

antidose for opioid toxicity

Answer 20

naloxone

Question 21

toxidrome symptoms of serotonin toxicity

Answer 21

• akathisia, tremor, clonus, altered mental status, sustained clonus, musclular hypertonicity, hyperthermia.

Question 22

serotonin syndrome toxidrome

Answer 22

increased bowel sounds, autonomic instability (often hypertensive), tachycaria, agitation, diaphoresis, mydriasis, clonus (especially in lower extremities) , tremor and hyperreflexia.

Question 23

treatment for serotonin syndrome (ie, treat the symptoms)

Answer 23

cooling: cold IV fluids, ice packs in groin and axilla, water msting/evaporative cooling

decrease the rigidity; NEED BENZOS, paralysis to prevent over ridigity– you must intubate them if you paralyze them), CYPROHEPTADINE is a possible antitode but it’s not really good.