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INTERNAL MEDICINE > CHAPTER 450 POISONING AND DRUG OVERSE > Flashcards

CHAPTER 450 POISONING AND DRUG OVERSE Flashcards

1
Q

it refers to the development of dose-related adverse effects following exposure to chemicals, drugs, and other xenobiotics

A

poisoning

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2
Q

age prone to poisioning

A

<6 years old

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3
Q

major reason for increased number of poisoning deaths

A

opoids

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4
Q

unintentional exposures include

A 
improper use of chemicals at work or play
label misleading
product mislabel
mistaken identification
unlabeled chemicals
uninformed self medication
dosing errors
elderly
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5
Q

most common reported reason for intentional poisoning

A

recreational use of ethanol

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6
Q

pharmaceutical agent most often implicated in fatal poisoning

A

acetaminophen

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7
Q

leading cause of death from poisoning

A

carbon monoxide

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8
Q

correct diagnosis established by

A

history, physical examination, routine and toxicologic laboratory evaluations and clinical course

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9
Q

history includes:

A 
time
route
duration 
circumstances 
the name and dose
chemical involved
the time of onset
nature and severity of symptoms
time and type of first aid used
medical and psychiatry history
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10
Q

if the px is confused or comatose suspect?

A

history of psychiatry problems
recent changes of economic and relationship status
work with chemicals

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11
Q

what is body packing or body stuffing

A

ingesting or concealing drugs in the body cavity

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12
Q

relevant information may be available from

A 
family 
friends
paramedics
police
pharmacist
physicians 
employers
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13
Q

it focuses the vital signs, and the systems

A

physical examination

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14
Q

neurologic status includes the:

A

documentation of the neuromuscular abnormalities such as dyskinesia, dystonia, fasciculations, myoclonus, rigidity and tremors

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15
Q

examine the eye for:

A

nystagmus and pupil size and reactviity

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16
Q

examine the abdomen for:

A

bowel activity and bladder size

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17
Q

examine the skin for:

A 
burns
bullae
color
warmth
moisture
pressure sores
puncture marks
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18
Q

what to do when history is unclear?

A

examine all the orifices for the presence of chemical burns, and drug packets

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19
Q

it also provide important diagnostic clues

A

odor of breath
vomitus
color of the nails and skin and urine

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20
Q

how to diagnose a poisoning in cases of unknown etiology

A

relies on pattern recognition

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21
Q

how to detect pattern recognition to diagnose poisoning in unknown etiology

A

first: assess the pulse, blood pressure and respiratory rate and temperature and neurologic status and characterized the overall physiologic state as stimulated, depressed, discordant or normal
second: identify the pathophysiologic patterns or toxic syndrome (toxidrome)
third: identify the particular agent involved by looking at the unique poison specific physical or ancillary test abnormalities

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22
Q

most reliable prognosticator of poor outcome in poisoning from stimulants

A

temperature elevation

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23
Q

what are the 4 physiologic state

A

stimulated
depressed
discordant
normal

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24
Q

stimulated physiologic state is characterized by

A

increased pulse, bp rr, temp and neuromuscular activity

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25
Q

stimulated physiologic state reflects the

A

symphathetic, anticholinergic or hallucinogen poisoning or drug withdrawal

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26
Q

feature of all stimulants and is most marked in anticholinergic poisoning since the pupillary reactivity relies on muscarinic control

A

mydriasis

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27
Q

anticholinergic syndrome is characterized by:

A

hot dry flushed skin
decreased bowel sounds
urinary retention
other: diaphoresis, pallor and increased bowel activity with nausea, diarrhea

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28
Q

findings that suggest sympathetic poisoning

A

increased vital signs and organ ischemia

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29
Q

selective alpha adrenergic stimulants such as decongestants can cause

A

reflex bradycardia

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30
Q

selective beta-adrenergic stimulants such as asthma therapeutics can cause

A

hypotension

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31
Q

ergot alkaloids can cause

A

limb ischemia

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32
Q

phencylidine and ketamide can cause

A

rotatory nystagmus

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33
Q

cocaine can cause

A

delayed cardiac contraction

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34
Q

what do seizures suggest

A

sympathetic etiology

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35
Q

state characterized by mixed vital signs and neuromuscular abnormalities

A

discordant physiologic state

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36
Q

cause of depressed physiological state

A

functional sympatholytics (agents that decrease cardiac function and vascular tone)
cholinergic such as muscarinic and nicotinic agents
opiods
sedatives

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37
Q

feature that is most pronounced in opiods and cholinergic poisoning

A

miosis

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38
Q

other clues that may suggest physiologic depressed state

A 
cardiac arrhythmias
conduction disturbances
mydriasis 
nystagmus
seizures
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39
Q

what can cause arythmias and conduction disturbances

A 
antiarrhythmias
calcium channel blocker
digitalis
glycosides
propoxyphene
cyclic antidepressants
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40
Q

what can cause mydriasis

A

tricyclic antidepressants and some antiarrhymics, meperidine and diphenocylate atropine such as lomotil

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41
Q

what can cause nystagmus

A

sedative hypotics

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42
Q

what can cause seizures

A

cholinergic agents
propoxyophene
cyclic depressants

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43
Q

physiologic state characterized by decreased pulse, bp, rr, and temp and neuromuscular activity

A

depressed physiologic state

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44
Q

cause of normal physiologic state

A

non-toxic exposure
psychogenic illness
poisoning of toxic time bombs that are slowly absorbed and slowly distributed and require metabolic activation

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45
Q

laboratory result most common in advanced methanol, ethylene glycol and salicyate intoxication

A

increased anion gap metabolic acidosis

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46
Q

what happens when there is increased blood levels of bromide, calcium, iodide, lithium or magnesium

A

abnormally low anion gap

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47
Q

a difference of >10 mmol per liter between serum osmality suggests the presence of low molecular weight solute such as acetone, alcohol , glycol, and ether, or sugar

A

a difference of >10

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48
Q

ketosis suggest of

A

acetone, iso alcohol, salicylate poisoning or alcoholic ketoacidosis

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49
Q

hypokalcemia suggest of

A

beta-adrenergic blocker, caffeine, diuretics, theophylline, toleune

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50
Q

hyperkalcemia suggest of

A

poisoning of alpha adrenergic agonist
beta adrenergic blocker
cardiac glycosides
fluoride

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51
Q

hypocalcemia suggest of

A

ethylene glycol
fluoride
oxalate poisoning

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52
Q

result of ECG in px poisoned with alpha adrenergic agonist, beta blockers, calcium channel blockers and cholinergic agents

A

bradycardia and atrioventricular block

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52
Q

QRS and QT interval prolongation is caused by

A

hyperkalemia
antidepressants
membrane active drugs

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53
Q

ventricular tacycardia suggests

A

poisoning with cardiac glycosides
fluorides
membrane active drugs

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54
Q

radiologic result in px with posoining of carbon monoxide, cyanide and opiods

A

pulmonary edema

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55
Q

aspiration pneumonia is common in px with

A

coma
seizures
petroleum distillate aspiration

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56
Q

what can be used to rule out and confirm suspected poisoning

A

toxicologic analysis

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56
Q

what can be used to rule out and confirm suspected poisoning

A

toxicologic analysis

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57
Q

screening test that should not be used because it cannot confirm the exact identity of the detected substance

A

rapid qualitative hospital-based urine test

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58
Q

useful for diagnostic purposes

A

response to antidotes

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59
Q

resolution of altered mental status and abnormal vital signs within minutes of IV administration of dextrose, naloxone, or flumazenil is diagnostic of

A

hypoglycemia
opoid poisoning
benzodiazepine intoxication

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60
Q

grade of physiologic stimulation that is anxious, irritable but the vital signs are normal with diaphoresis with flushing and pallor, mydriasis and hyperflexia sometimes present

A

grade 1 physiologic stimulation

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61
Q

grade of physiologic stimulation that is agitated may have confusion or hallucinations but can converse and follow commands but the vital signs are mild to moderately increased

A

grade 2 physiologic stimulation

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62
Q

Grade of physiologic stimulation that is delirious, unintelligible speech, uncontrollable motor hyper-activity moderately increased vital signs and tachyarrhythmias are possible

A

grade 3 f physiologic stimulation

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63
Q

grade of physiologic stimulation that is in coma, seizures and in cardiovascular collapse

A

grade 4 physiological stage stimulation

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64
Q

grade of depressed if the px is awake, lethargic or sleeping but arousable by voice or tactile stimulation and able to converse and follow commands but may be confused

A

Grade 1 physiologic depression

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65
Q

grade of physiologic depression if the px responds to pain but not to voice can vocalize but not converse with the spontaneous motor activity present with brainstem reflexes intact

A

grade 2 physiologic depression

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66
Q

grade of physiologic depression that is unresponsive to pain, spontaneous motor activity absent with brainstem reflexes depressed, motor tone, respirations and temperature decreased

A

grade 3 physiologic depression

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67
Q

grade of physiologic depression that is unresponsive to pain, flaccid paralysis, brainstem reflexes and respirations absent with cardiovascular vital signs decreased

A

grade 4 physiologic depression

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68
Q

what are the treatment goals for poisoning and drug overdose

A 
support of vital signs
prevention of further poisoning absorption
enhancement of poison elimination
administration of specific antidotes
prevention of re-exposure
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69
Q

what is the highest priority in the pre-toxic phase?

A

decontamination and treatment are solely based on history and pe

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70
Q

when history is not obtainable and poison is causing delayed toxicity what is the appropriate best thing to do?

A

blood and urine samples were sent for toxicologic screening and quantitative analysis

71
Q

what is toxic phase

A

interval between the onset of poisoning and its peak effect

72
Q

management during toxic phase

A

based on laboratory and clinical findings

73
Q

when does the effect of overdose manifested

A

begin sooner and peak later and last longer than they do after a therapeutic dose

74
Q

what is the first priority

A

resuscitation and stabilization

75
Q

what to give in px with altered mental status that has come and seizures

A

intravenous glucose
naloxone
thiamine

76
Q

measures that enhance the decontamination of salicylates

A

urinary alkanization

77
Q

enhance decontamination in metals

A

chelation therapy

78
Q

what is the goal of supportive therapy

A

maintain the physiologic homeostasis until detoxification is accomplished and to prevent and treat secondary complications

79
Q

indications for admission in intensive care unit

A

patients with severe poisoning (coma, respiratory depressionm hypotension, cardiac conduction abnormalities, cardiac arrythmias
those needing close monitoring

80
Q

respiratory care to prevent aspiration of gastrointestinal contents especially in those with CNS depressions and seizures

A

endotracheal intubation

81
Q

respiratory care for px with respiratory depression or hypoxemia and for facilitation of therapeutic sedationn or paralysis of patients in order to prevent or treat hyperthermia, acidosis and rhabdomyolysis associated with neuromuscular hyperactivity

A

mechanical ventilation

82
Q

oxygenation and ventilation is best determined by

A

pulse oximetry and arterial blood gas analysis

83
Q

not a reliable indicator for the need of intubation

A

gag reflex

84
Q

if the px hypotension is unresponsive to volume expansion and appropriate next step is?

A

treatment with norepinephrine and epinephrine and high dose dopamine

85
Q

what should be considered in px with severe but reversible cardiac failure

A

intraaortic balloon pump counterpulsation

venoarterial or cardiopulmonary perfusion techniques

86
Q

treatment for sympathetic hyperactiviity

A

benzodiazepine

87
Q

treatment for anticholinergic posoining

A

physostigmine

88
Q

treatment for ventricular arrhythmia

A

sodium bicarbinate
lidocaine
phenytoin

89
Q

treatment in px with torsades de pointed and prolonged QT intervals

A

magnesium sulfate and overdrive pacing

90
Q

treatment for severe cardiac glycoside poisoning

A

magnesium and anti digoxin antibodies

91
Q

seizures caused by excessive stimulation of catecholamine receptors is treated with

A

agents that enhance GABA activity such as benzodiazepine and barbiturates

92
Q

seizures caused by isoniazid are treated with

A

pyridoxine

93
Q

what is contraindicated in toxicologic seizures

A

phenytoin

94
Q

serotonergic receptor overstimulation is serotonin syndrome is treated with?

A

cyproheotadine

95
Q

the average time from ingestion to presentation of adults

A

> 3 hours

96
Q

the average time of ingestion to presentation of children

A

> 1 hour

97
Q

preferred method of gastrointestinal decontamination that has fewer contraindications and complications

A

activated charcoal

98
Q

mechanism of action of charcoal

A

the charcoal adsorbs ingested poisons within the gut lumen allowing the charcoal toxin complex to be evacuated in stool

99
Q

what compounds that are not well absorb in charcoal

A

charged ionized chemicals such as mineral, acid, alkalis, and highly dissociated salts of cyanide, fluoride, iron, lithium and other inorganic compounds

100
Q

side effects of charcoal

A

nausea, vomiting, and diarrhea or constipation and prevents the absorption off orally administered therapeutic agents

101
Q

complications of charcoal

A

mechanical obstruction of airway, aspiration, vomiting, and bowel obstruction and infarction caused by inspissated charcoal

102
Q

when is charcoal not recommended

A

ingested corrosives because it will obscure endoscopy

103
Q

what method is preferred for life-threatening poisons that cannot be treated with other method

A

gastric lavage

104
Q

how is gastric lavage performed?

A

performed by sequentially administering and aspirating 5 ml of fluid per kilogram of body weight through a no.40 French orogastric tube (no. 28 for children)

105
Q

preferred solute used in gastric lavage in infants

A

normal saline and tap water

106
Q

the positon of px when doing gastric lavage to prevent aspiration

A

trendelenburg and left lateral decubitus

107
Q

lavage absoprtion within 5 mins, 30 mins and 60 mins of ingestion

A

decreases as time lengthens

108
Q

common complication of gastric lavage

A

aspiration

109
Q

serious complication of gastric lavage

A

esophageal and gastric perforation and tube misplacement

110
Q

contraindicated in gastric lavage

A

corrosive
petroleum distillate ingestions because the risk of gastroesophageal perforation and aspiration pneumonitis
compromised airway
risk of hemorrhage or perforation due to esophageal or gastric pathology
recent surgery
px who refuse

111
Q

emetogenic agent that is once used in decontamination but no longer used in decontamination

A

syrup of ipecac

112
Q

chronic use of ipecac complications

A

electrolyte and fluid abnormalities, cardiac toxicity, and myopathy

113
Q

another method for gastric decontamination that is performed by administering bowel cleansing solution that contains electrolytes and polyethylene glycol

A

whole bowel irrigation

114
Q

whole bowel irrigation is appropriate in px with

A

ingested foreign bodies
packets of ilicit drugs
and heavy metals

115
Q

salts given together with charcoals to promote the rectal evacuation of gastrointestinal contents

A

cathartics

116
Q

side effects of cathartics

A

abdominal pain
nausea
occasional vomitting

117
Q

complications of repeated doses of cathartics

A

severe electrolytes disturbances and excessive diarrhea

118
Q

contraindications of cathartics

A

ingested corrosives and with preexisting diarrhea

119
Q

when is dilution recommended

A

only after the ingestion of corrosives

120
Q

technique used in rare situations such as ingestions of potentially toxic foreign bodies

A

endoscopic or surgical removal

121
Q

initial treatment for for topical exposures

A

immediate copious flushing with water and saline

122
Q

preferred for eye irrigation

A

saline

123
Q

treatment for inhlational exposures

A

supplemental oxygen or fresh air

123
Q

treatment for inhlational exposures

A

supplemental oxygen or fresh air

124
Q

treatment for dermal decontamination

A

triple wash

125
Q

removal of liquids in cavities such as vagina and rectum

A

irrigation

126
Q

when is multiple-dose of charcoal therapy considered

A

ingestion of theophyline, phenobarbital, carbamazepine, dapsone and quinine

127
Q

complications of multiple-dose charcoal therapy

A

intestinal obstructions, pseudo-obstruction and nonoccluisive intestinal infarction in px with decreased gastric motility

128
Q

how urinary alkalinization works

A

ion trapping via alteration of urine ph may prevent the renal absorption of poisons that undergo excretion by glomerular filtration and active tubular secretion

129
Q

what ions are trapped in the membrane

A

acidic are ionized and trapped in alkaline urine whereas basic become ionized and trapped in acid urine

130
Q

urine alkalinization urine ph

A

ph >7.5 and urine output of 3-6 ml of body weight per hour by the addition of sodium bicarbonate to an IV solution

131
Q

contraindication of urinary alkalinization

A

congestive heart failure, renal failure and cerebral edema

132
Q

agents most amenable to enhance elimination bu dialysis

A 
low molecular mass <500
high water solubility
low protein binding
small volumes of distirbutio (<1l)
prolonged elimination (long half life)
high dialysis clearance relative to total body clearance
133
Q

when is dialysis considered

A

severe poisoning due to carbamazepine, ethylene glycol, isoprophyl alcohol, lithium, methanol, theophyline, salicylates and valproate

134
Q

candidates for extracorporeal removal

A

px with severe toxicity whose condition deteriorates despite the aggressive supportive therapy, those with potentially prolonged irreversible or fatal toxicity, those with dangerous blood level of toxins, those who lack capability for self detoxification because of liver or renal failure and those with serious underlying illness or complication that will adversely affect recovery

135
Q

how do antidotes work

A

counteract the effect of poisons by neutralizing them or by antagonizing their physiologic effect by activation of opposing nervous system activity, provision of competitive metabolic or receptor substance

136
Q

how to prevent re-exposure

A

limit their access to poisions

137
Q

fundamentals of supportive care in poisoning management

A 
airway protection
oxygenation/ventilatiom
treatment of arrythmias
hemodynamic support
treatment of seizures
correction of temperature and abnormalities
correction of metabolic derangement
prevention of secondary complications
138
Q

fundamentals in prevention of further poisoning absoprtion

A

gastrointestinal decontamination such as gastric lavage, activated charcoal, whole bowel irrigation,dilution and endoscopic surgical removal and decontamination of other sites such as eye, skin and body decontamination

139
Q

fundamentals in enhancement of poison elimination

A

multiple dose activated charcoal
alteration of urine ph
chelation
extracorpeal removal

140
Q

causes of stimulated physiologic condition

A

sympathetic such as sympathomimetics, ergot alkaloids, methylxanthines, monoamide oxidase inhibitors
anticholinergics such as antihistamines, antipsychotics and belladona alkaloids, cyclic depressants and mushroom and plants

141
Q

examples of sympathomimetics

A

a1 adrenergic agonist and b2 adrenergic agonist

142
Q

mechanism of action of sympathomimetics

A

stimulation of central and peripheral sympathetic receptor directly or indirectly (release and inhibit release of norepi and dopamine)

143
Q

mechanism of action of sympathomimetics

A

stimulation of central and peripheral sympathetic receptor directly or indirectly (release and inhibit release of norepi and dopamine)

144
Q

clinical features of sympathomimetics

A

a1- reflex bradycardia

b- hypotension and hypokalemia

145
Q

treatmen of sympathomimetics

A

phentolamine-severe hypertension

labetalol-hypotension and tacycardia

146
Q

examples of ergot alkaloids

A

ergotamine
methysergide
bromocriptine
pergolide

147
Q

mechanism of action of ergot alkaloids

A

stimulation and inhibition of serotonergic and a adrenergic receptors
simulation of dopamine receptors

148
Q

clinical features of ergot alkaloids

A

formication and vasospasm with limb, myocardial and cerebral ischemia to gangrene and involuntary movements

149
Q

treatment for ergot alkaloids

A

nitroprusside or nitroglycerine for vasopasm
prazosin, captopril- limb ischemia
dopamine for movement disorders

150
Q

examples of methyxanthines

A

caffeine and theophylline

151
Q

mechanism of action of methylxanthines

A

inhibition of adenosine synthesis and adenosine receptor antagonism
stimulation of epi and norepi release
inhibition of phosphodiesterase-increased intracellular cyclic adenosine and guanosine monophosphate

152
Q

clinical features of methylxanthines

A

pronounced gastrointestinal symptoms

toxicity occur at lower drug level in chronic than in acute

153
Q

treatment of methylxanthines

A

propranolol for tacycardia with hypotension

beta blocker for supraventricular or ventricular tacycardia

154
Q

indications for hemoperfusion and hemodialysis

A

unstable vital signs
seizures
theophylline level of 80-100 after acute overdose and 40-60 with chronic exposure

155
Q

example of monoamide oxidase inhibitors

A

phenelzine
tranycypromine
selegiline

156
Q

mechanism of action of monoamine oxidase inhibitors

A

inhibition of monoamide oxidase resulting in impaired metabolism of endogenous catecholamines and exogenous sympathomimetic agent s

157
Q

clinical feature of monoamine oxidase inhibitors

A

delayed and slowly progressive

terminal hypotension and bradycardia in severe cases

158
Q

treatment of monoamine oxidase inhibitors

A

short acting agents such as nitroprusside and esmolol for severe hypotension and tacycardaia
direct acting sympathomimetic: norepi and epi for hypotension and bradycardia

159
Q

examples of anticholinergic agents

A 
antihistamines
antipsychotics
belladonna alkaloids
cyclic antidepressants
mushrooms and plant s
160
Q

examples of anti-histamines

A

diphenydramine
doxylamine
pyrilamine

161
Q

mechanism of action of antihistamines

A

inhibition of central and postganglionic parasympathetic muscarinic cholinergic receptors

162
Q

clinical features of anti-histamines

A 
dry skin
mucous membranes
decreased bowel movements
flushing
urinary retention
myoclonus
picking activity
163
Q

treatment of antihistamines

A

physostigmine for delirium and neuromuscular hyperactivity

164
Q

examples of antipyschotics

A

chlorpromazine
olanzapine
quetiapine
thioridazine

165
Q

mechanism of action of antipsychotics

A

inhibition of alpha adrenergic dopaminergic histaminergic muscarinic and serotonegic receptors
inhibit sodium, pottasium and calcium channles

166
Q

clinical features of antipsychotics

A

miosis
anticholinergic effects
extrapyramidal effects
tachycardia

167
Q

treatment for antipsychotics

A

sodium bicarbonate for ventricular tachydysrhymias

magnesium, isoproterenol in torsades des pointes

168
Q

examples of belladonna alkaloids

A

atropine
hyoscyamine
scopolamine

169
Q

mechanism of action of belladonna alkaloids

A

inhibition of central and pots-ganglionic parasympathetic muscarinic cholinergic receptors

170
Q

clinical features of belladonna alkaloids

A 
dry skin
mucous membrane
decreased bowel sounds
flushing
urinary retention
myoclonus
picking activity
171
Q

treatment for belladonna alkaloids

A

physostigmine

172
Q

examples of cyclic depressants

A

amitriptyline
dexopine
imipramine

173
Q

mechanism of action of cyclic depressants

A

inhibition of alpha adrenergic dopaminergic , histaminergic and muscaranic and serotonergic receptors
inhibition of nore and epi
inhibition of serotonin reuptake

174
Q

clinical features of cyclic antidepressants

A 
seizures
tachycardia
cardiac
conduction delays
anticholinergic toxidrome
175
Q

treatment of cyclic depressants

A

hypertronic sodium bicarbonate

INTERNAL MEDICINE (12 decks)

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