Chapter 81: Emergency Preparedness, Toxicology & Antidotes

Question 1

Which resources have information on toxicology

Answer 1

Micromedex POISONDEX & Lexicomp Lexi-Tox

Question 2

To reduce accidental poisoning in children, what can be helpful

Answer 2

child-resistant containers

Question 3

What is required for all rx drugs unless waived by the patient

Answer 3

child-resistant containers

Question 4

Which drug is excluded from child-resistant containers

Answer 4

Nitroglycerin SL tabs

Question 5

Common child-resistant packaging includes

Answer 5

• Screw caps
• Unit dose packaging
• Card adherence
• Safety packaging

Question 6

Topical overdose management

Answer 6

Remove contaminated clothing and wash skin with soap and water for 10 min

Question 7

Ocular overdose management

Answer 7

remove contact lenses and rinse eye/s with a gentle stream of water for at least 15 min

Question 8

Which drug is no longer available but used to induce emesis for certain exposures

Answer 8

Ipecac syrup

Question 9

The first step to the CAB’s (circulation, airway, breathing) is

Answer 9

to evaluate if the pt has a pulse

Question 10

When is activated charcoal most effective

Answer 10

when used within 1 hour of ingestion

Question 11

How does activated charcoal work

Answer 11

it absorbs the drug, which prevents GI absorption and systemic toxicity

Question 12

What is the dose of activated charcoal

Answer 12

1 g/kg

Question 13

What must be done prior to using activated charcoal

Answer 13

airway should be protected (with intubation, if needed) to prevent aspiration

Question 14

Activated charcoal CI

Answer 14

• when the airway is unprotected (unconscious, cannot clear throat, cannot hold head upright)
• intestinal obstruction
• when GI tract is not intact or when there is decreased parastalsis

Question 15

Hepatotoxicity is a dose-dependent adverse effect caused by the increased metabolism of APAP by CYP450 ___ to ____

Answer 15

2E1 to NAPQI

Question 16

Phase 1 of APAP overdose

Answer 16

1-24 hrs: commonly asymptomatic or non-specific symptoms such as nausea and vomiting

Question 17

Phase 2 of APAP overdose

Answer 17

24-48 hrs: elevated INR, AST/ALT; symptoms from phase 1 usually subside

Question 18

Phase 3 of APAP overdose

Answer 18

48-96 hrs: fulminant hepatic failure (e.g., jaundice, coagulopathy, renal failure, &/or death)

Question 19

Phase 4 of APAP overdose

Answer 19

> 96 hrs: the patient recovers or receives a liver transplant

Question 20

Antidote for APAP overdose

Answer 20

N-acetylcysteine (NAC)

Question 21

How does NAC work for APAP overdose

Answer 21

Increases glutathione, which increases GSH.
GSH converts NAPQI to mercapturic acid, which can safely be excreted from the body.
If NAPQI has already bonded to hepatocytes, the damage is irreversible

Question 22

APAP levels are plotted on

Answer 22

Rumack-Matthew nomogram to determine risk of hepatotoxicity

Question 23

What formulations does NAC come in

Answer 23

oral and IV

Question 24

NAC brand name

Answer 24

Acetadote

Question 25

When is the APAP level drawn

Answer 25

4-24 hrs

Question 26

How is oral NAC dosed

Answer 26

high-dose bolus x1, then lower dose for 17 dose. Repeat the dose if emesis occurs within 1 hr of administration

Question 27

How is IV NAC dosed

Answer 27

3 infusions over a total of 21 hrs

Question 28

Anticholinergic overdose symptoms

Answer 28

Flushing, dry skin, mydriasis with double or blurry vision

Question 29

Anticholinergic overdose treatment

Answer 29

Primarily supportive care, rarely psysostigmine

Question 30

Treatments for warfarin OD

Answer 30

Phytonadione (Vitamin K) | Prothrombin complex concentrate (Kcentra)

Question 31

Treatments for factor Xa inhibitor OD

Answer 31

Prothrombin complex concentrate (Kcentra)

Question 32

Treatment for heparin & LMWH OD

Answer 32

Protamine

Question 33

Treatments for dabigatran OD

Answer 33

Idarucizumab (Praxbind)

Question 34

Treatments for apixaban & rivaroxaban OD

Answer 34

Abdexanet alfa (Andexxa)

Question 35

Treatment for BZD OD

Answer 35

Flumazenil - can cause seizures when used in pts on BZDs chronially

Question 36

Treatment for BB OD

Answer 36

Glucagon (if unresponsive to symptomatic tx)

Question 37

Treatment for CCB OD

Answer 37

Calcium chloride or gluconate (administer Ca IV only)

Question 38

Cyanide: smoke inhalation, nitroprusside in high doses/long durations/renal impairment treatment for OD

Answer 38

Hydroxocobalamin (Cyanokit)

Question 39

Treatment for digoxin OD

Answer 39

Digoxin Immune Fab

Question 40

What should be administered for ethanol OD if suspected to be a chronic alcohol user

Answer 40

thiamine (B1) to prevent Wernicke's encephalopathy | Can cause increased anion gap

Question 41

Treatment for arsenic, gold, mercury OD

Answer 41

Dimercaprol

Question 42

Treatment for copper OD

Answer 42

Penicillamine

Question 43

Treatment for lead OD

Answer 43

Succimer

Question 44

In patient's with Hydrocarbon OD (petroleum products, gaosline, kerosene, mineral oil, paint thinners), what should be avoided

Answer 44

Do not induce vomiting; keep pt NPO d/t aspiration risk

Question 45

Treatment for insulin or other hypoglycemic OD

Answer 45

- Dextrose injection or infusion (drip), oral glucose (do not administer if pt is unconscious) - Glucagon (when IV or oral dextrose cannot be administered)

Question 46

Treatment for isoniazid OD

Answer 46

Pyridoxine (B6)

Question 47

Iron & aluminum OD treatment

Answer 47

Deferoxamine (Desferal)

Question 48

Symptoms of organophosphate OD

Answer 48

OPs block acetylcholinesterase, which increases ACh levels and causes cholinergic "SLUDD" sx: salivation, lacrimation, urination, diarrhea/defecation

Question 49

Treatment for organophosphate, including industrial insecticide, OD

Answer 49

Atropine | pralidoxime: treats muscle weakness and relieves paralysis of respiratory muscles by reactivating cholinesterase

Question 50

Treatment for MTX OD

Answer 50

Leucovorin (folinic acid), levoleucovorin (Fusilev)

Question 51

Methylene blue is CI in pts with

Answer 51

G6PD deficiency

Question 52

Treatment for neostigmine, pyridostigmine OD

Answer 52

Pralidoxime

Question 53

Early sx of nicotine OD

Answer 53

abdominal pain, nausea

Question 54

Treatment for nicotine OD

Answer 54

Supportive care (e.g., atropine for symptomatic bradycardia, BZDs for seizures)

Question 55

Treatment for salicylate OD

Answer 55

Sodium bicarbonate (alkylating agent to alkalinize the urine to decrease drug absorption and increase excretion of salicylates)

Question 56

Stimulant OD treatment (including ADHD and weight loss drugs)

Answer 56

supportive care for agitation or seizures (BZDs)

Question 57

Toxic alcohols, ethylene glycol (antifreeze), methanol treatment for OD

Answer 57

Can cause increased anion gap | Fomepizole

Question 58

OD of TCAs can quickly cause

Answer 58

fatal arrhythmias

Question 59

TCA OD treatment

Answer 59

Sodium bicarbonate to decrease a widened QRS complex

Question 60

Valproic acid or topiramate-induced hyperammonemia treatment

Answer 60

Levocarnitine

Question 61

What are the SLUDD symptoms for organophosphate OD

Answer 61

``` Salivation Lacrimation Urination Diarrhea Defecation ```

Question 62

What is the combination of atropine and pralidoxime called for organophosphate OD

Answer 62

Duodote

Question 63

Antidote for animal bites

Answer 63

Rabies vaccine with Human rabies immune globulin

Question 64

Black Widow spider bites and scorpion sting antidote

Answer 64

Antivenin

Question 65

Snake bite antidote

Answer 65

Crotalidae polyvalent immune FAB (Crofab) for copperhead and rattlesnake bites