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Rosens Chapters > Ch. 139 Approach to the Poisoned Patient > Flashcards

Ch. 139 Approach to the Poisoned Patient Flashcards

1
Q

Key things to know for any poisoned patient

A

What, how much, when, what route, other co-exposures

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2
Q

When a poisoned patient is not cooperative, or is obtunded and can’t participate in the exam, what signs and symptoms can be observed to help guide diagnosis and management?

A 
Vitals!
Mental state
Pupils
Seizure activity
Skin color and moisture level
Muscle tone, rigidity, or clonus
Smells

If cooperative, a temperature is important

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3
Q

What are the most commonly described toxidromes?

A 
Sympathomimetic
Anticholinergic
Cholinergic
Sedative/Hypnotic
Opioid

Others: serotonin syndrome, NMS

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4
Q

What are the classic features of sympathomimetic toxidrome?

A

Fight or flight response:
Increased HR, RR, BP, Temp
Mydriasis, diaphoresis
Severe: decreased cardiac output, arrhythmia, circulatory collapse

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5
Q

What are the classic features of anticholinergic toxidrome?

A

Blocking parasympathetic outflow allows unopposed sympathetic tone leading to similar symptoms of sympathomimesis, including:
hyperthermia, mydriasis, skin flushing, delirium
Difference from sympathomimetic:
dry mucous membranes and dry skin

mad as a hatter, hot as a hare, dry as a bone, blind as a bat, red as a beet, full as a flask

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6
Q

Which toxidrome is mad as a hatter, hot as a hare, dry as a bone, blind as a bat, red as a beet?

A

Anticholinergic

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7
Q

Which toxidrome causes fluids to come from every orifice?

A

Cholinergic

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8
Q

Patient has diaphoresis, urination, miosis, bronchorrhea, emesis, lacrimation, lethargy and salivation.
Which toxidrome?

A

Cholinergic

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9
Q

What are the classic agents causing cholinergic toxidromes?

A

Organophosphates and insecticides

Also caused by nerve gas

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10
Q

How do people die when poisoned by cholinergic agents such as nerve gas?

A

Bronchorrhea: essentially drowning in own secretions

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11
Q

What are the features of a nicotine poisoning?

A 
(Days of the week)
Mydriasis
Tachycardia
Weakness
Tremors
Fasciculations
Seizures
Somnolent
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12
Q

What are the common agents causing sedative/hypnotic toxidrome?

A

Alcohol
Barbiturates, Benzos
Gamma hydroxybutyrate

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13
Q

What is important to remember to look for with sedative toxidromes because of common coincidence?

A

Traumatic injuries

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14
Q

What are the features of opioid toxidrome?

A

Sedation, depressed respiratory drive, miosis, and response to naloxone

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15
Q

What are the common agents associated with serotonin syndrome?

A

SSRI’s
MAOI’s
Cyclic antidepressants, atypical antipsychotics

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16
Q

What are the features of serotonin syndrome?

A 
AMS
Hyperthermia
Agitation
Hyperreflexia
Clonus
Diaphoresis
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17
Q

What is the underlying cause of neuroleptic malignant syndrome and how is the syndrome similar and different to serotonin syndrome?

A

Caused by low dopamine leading to stronger serotonin making a similar presentation of AMS, agitation and hyperthermia
Different from serotonin syndrome in that it causes rigidity and decreased reflexes without clonus

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18
Q

What is the mnemonic for evaluating altered mental status and what does each letter stand for?

A 
Alcohol/acidosis
Encephalopathy/electrolytes
Infection
Opioids/overdose
Uremia

Trauma
Insulin (hyper/hypoglycemia)
Psychosis
Seizure/Stroke

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19
Q

What is one of the most important things to always remember when evaluating a patient with a suspected toxidrome or altered mental status?

A

Keep the differential broad!

Consider all causes of AMS, look for co-ingestions and trauma and expect the information given to you to be inaccurate

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20
Q

What are the routine labs done in a tox patient?

A

CBC, Chemistry, LFT’s, UA, Pregnancy, Lactate, Alcohol, ASA, Acetaminophen, UDS, glucose

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21
Q

What are the causes of normal anion gap metabolic acidosis?

A

Diarrhea and renal tubular acidosis

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22
Q

When is water not used for decontamination because it can cause an explosion?

A

Metallic potassium, magnesium or sodium
(found in tracer ammunition)
These are covered with mineral oil or petroleum jelly

23
Q

When is gastric lavage indicated?

A

This is basically never indicated anymore due to risks of esophageal trauma, aspiration.
Indications: within 1 hour of ingestion of a life-threatening substance that does not absorb to charcoal and no antidote exists and in a facility with appropriate expertise to do the procedure

24
Q

What are the recommendations using charcoal?

A

Routine use is not recommended, but only is specific ingestions
Within one hour of ingestion
Pt is alert, cooperative, and expected to be able to maintain airway throughout ingestion
And it is either a high toxicity substance or is toxic and slow release, or there is evidence of a large ingestion of a toxic agent
Substance is amenable to charcoal

25
Q

When is charcoal contraindicated?

A

Pt is sedated, can’t protect airway, or is unwilling to drink

Should not be given in low toxicity, or if there is a good antidote available

26
Q

Should an NG tube be placed solely to instill charcoal?

A

No. This increases risk of aspiration

27
Q

When should charcoal be given?

A

Drugs with high toxicity and lethality
Within 1 hour of ingestion in most cases
Drug is amenable to charcoal (not rapidly absorbed substances like alcohol)
Pt must be alert and compliant

28
Q

What are some of the potentially lethal ingestions that charcoal can be used for?

A 
"The Killer C's"
Cyanide
Colchicine
Calcium channel blockers
Cyclic antidepressants
Cardio glycosides
Cyclopeptide mushrooms
Cocaine
Cicutoxin (water hemlock)
Salicylates
29
Q

How is whole bowel irrigation done and when is it contraindicated?

A

Need 2L per hour of a balanced polyethylene glycol solution, usually through NG tube

Contraindicated in critically ill patients, hypoperfusion of the gut, and bowel obstruction

30
Q

What toxins are amenable to dialysis?

A 
(STUMBLED)
Salicylates
Theophylline
Uremia
Metformin/methanol
Barbiturates
Lithium
Ethylene glycol
Depakote
31
Q

Describe serum alkalinization and how it is done.

A

Best for salicylates, prevents crossing BBB
Must monitor serum pH and bicarbonate level as well as urine pH
Goal serum pH of 7.5 and urine pH of 8.0
Care must be taken with potassium levels because alkalinization will drive K+ into the cells making the kidneys reverse all the work you are doing, so you must supplement with K+

3 amps (150 mEq) 8.4% bicarb into liter of D5W and add potassium 20-40 mEq and give no faster than 250cc/hr

32
Q

What is the general indication for fat emulsion therapy? What specific drug overdoses?
What are the proposed mechanisms of action?

A

Used for poison-induced cardiogenic shock
(local anesthetics, beta blockers, Ca channel blockers, cyclic antidepressants, bupropion, cocaine)

1) Acts as a lipid sink for lipid soluble drugs
2) Provides free fatty acids to the heart that act as an energy source, and also help to optimize cardiac calcium channels

33
Q

What are the preferred energy sources for the heart?

A

Normally, the heart likes free fatty acids

During times of stress, the heart switches to glucose

34
Q

What is required before giving IV fat emulsion (Intralipid)

What are the complications of its use?

A

Consultation with a toxicologist

Complications include: extreme lipemia messing up many labs, acute pancreatitis, ARDS

35
Q

The antidote for acetaminophen

A

N-acetylcysteine

36
Q

What is fomepizole used for?

A

Methanol/ethylene glycol

37
Q

What is the antidote for carbon monoxide?

A

Oxygen and hyperbarics

38
Q

What is the antidote for opioids?

A

Naloxone

39
Q

What is the antidote for anticholinergics?

A

Physostigmine (cholinesterase inhibitor)

40
Q

What is the antidote for Organophosphates?

A

Atropine/pralidoxime (2-PAM)

41
Q

What type of toxin is sarin gas?

A

Organophosphate

42
Q

How do organophosphates work?

A

Bind to acetylcholinesterase and inactive it leading to cholinergic syndrome

43
Q

How does pralidoxime work?

A

Binds to organophosphate-acetylcholinesterase molecule freeing the enzyme and renewing its function

44
Q

What is the antidote for methemoglobinemia?

A

Methylene blue

45
Q

What is the antidote for cyanide?

A

Nitrites/hydroxycobalamin

46
Q

What is the antidote for iron?

A

Deferoxamine

47
Q

What is dimercaprol used for?

A

arsenic, lead

48
Q

What is the antidote for lead and mercury?

A

Succimer

49
Q

What is the antidote for beta blockers?

A

Glucagon

50
Q

What is bicarbonate the antidote for?

A

Salicylates and TCA’s

51
Q

What is the antidote for calcium channel blockers?

A

Calcium, insulin/glucose

52
Q

What is the antidote for Isoniazid?

A

Pyridoxime (B6)

53
Q

What is the antidote for local anesthetic systemic toxicity?

A

IV fat emulsion

Rosens Chapters (13 decks)

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