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

Which drug is excluded from child-resistant containers

Answer 3

Nitroglycerin SL tabs

Question 4

Common child-resistant packaging includes

Answer 4

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

Question 5

Topical overdose management

Answer 5

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

Question 6

Ocular overdose management

Answer 6

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

Question 7

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

Answer 7

Ipecac syrup

Question 8

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

Answer 8

to evaluate if the pt has a pulse

Question 9

When is activated charcoal most effective

Answer 9

when used within 1 hour of ingestion

Question 10

How does activated charcoal work

Answer 10

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

Question 11

What is the dose of activated charcoal

Answer 11

1 g/kg

Question 12

What must be done prior to using activated charcoal

Answer 12

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

Question 13

Activated charcoal CI

Answer 13

• 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 paristalsis

Question 14

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

Answer 14

2E1 to NAPQI

Question 15

Phase 1 of APAP overdose

Answer 15

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

Question 16

Phase 2 of APAP overdose

Answer 16

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

Question 17

Phase 3 of APAP overdose

Answer 17

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

Question 18

Phase 4 of APAP overdose

Answer 18

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

Question 19

Antidote for APAP overdose

Answer 19

N-acetylcysteine (NAC)

Question 20

How does NAC work for APAP overdose

Answer 20

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 21

APAP levels are plotted on

Answer 21

Rumack-Matthew nomogram to determine risk of hepatotoxicity

Question 22

What formulations does NAC come in

Answer 22

oral and IV

Question 23

Acetadote generic name

Answer 23

NAC

Question 24

When is the APAP level drawn

Answer 24

4-24 hrs after ingestion

Question 25

How is oral NAC dosed

Answer 25

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

Question 26

How is IV NAC dosed

Answer 26

3 infusions over a total of 21 hrs

Question 27

Anticholinergic overdose symptoms

Answer 27

Flushing, dry skin, mydriasis with double or blurry vision

Question 28

Anticholinergic overdose treatment

Answer 28

Primarily supportive care, rarely physostigmine

Question 29

Treatments for warfarin OD

Answer 29

Phytonadione (Vitamin K) Prothrombin complex concentrate (Kcentra)

Question 30

Treatments for factor Xa inhibitor OD

Answer 30

Prothrombin complex concentrate (Kcentra)

Question 31

Treatment for heparin & LMWH OD

Answer 31

Protamine

Question 32

Treatments for dabigatran OD

Answer 32

Idarucizumab (Praxbind)

Question 33

Treatments for apixaban & rivaroxaban OD

Answer 33

Abdexanet alfa (Andexxa)

Question 34

Treatment for BZD OD

Answer 34

Flumazenil - can cause seizures when used in pts on BZDs chronially | not routinely recommended

Question 35

Treatment for BB OD

Answer 35

Glucagon (if unresponsive to symptomatic tx) | high dose insulin

Question 36

Treatment for CCB OD

Answer 36

Glucagon Calcium chloride or gluconate (administer Ca IV only)

Question 37

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

Answer 37

Hydroxocobalamin (Cyanokit)

Question 38

Treatment for digoxin OD

Answer 38

Digoxin Immune Fab (DigiFab)

Question 39

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

Answer 39

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

Question 40

Treatment for arsenic, gold, mercury OD

Answer 40

Dimercaprol

Question 41

Treatment for copper OD

Answer 41

Penicillamine

Question 42

Treatment for lead OD

Answer 42

Succimer (Chemet)

Question 43

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

Answer 43

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

Question 44

Treatment for insulin or other hypoglycemic OD

Answer 44

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

Question 45

Treatment for isoniazid OD

Answer 45

Pyridoxine (B6)

Question 46

Iron & aluminum OD treatment

Answer 46

Deferoxamine (Desferal)

Question 47

Symptoms of organophosphate OD

Answer 47

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

Question 48

Treatment for organophosphate, including industrial insecticide, OD

Answer 48

1. Atropine (anticholinergic effects) 2. pralidoxime (treats muscle weakness and relieves paralysis of respiratory muscles by reactivating cholinesterase) 3. combo of both

Question 49

Treatment for MTX OD

Answer 49

Leucovorin (folinic acid), levoleucovorin (Fusilev)

Question 50

Methylene blue is CI in pts with

Answer 50

G6PD deficiency

Question 51

Treatment for neostigmine, pyridostigmine OD

Answer 51

Pralidoxime (counteracts muscle weakness)

Question 52

Early sx of nicotine OD

Answer 52

abdominal pain, nausea

Question 53

Treatment for nicotine OD

Answer 53

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

Question 54

Treatment for salicylate OD

Answer 54

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

Question 55

Stimulant OD treatment (including ADHD and weight loss drugs)

Answer 55

supportive care for agitation or seizures (BZDs)

Question 56

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

Answer 56

Can cause increased anion gap **Fomepizole** is preferred, ethanol 2nd line

Question 57

OD of TCAs can quickly cause

Answer 57

fatal arrhythmias

Question 58

TCA OD treatment

Answer 58

Sodium bicarbonate to decrease a widened QRS complex

Question 59

Valproic acid or topiramate-induced hyperammonemia treatment

Answer 59

Levocarnitine

Question 60

What are the SLUDD symptoms for organophosphate OD

Answer 60

``` Salivation Lacrimation Urination Diarrhea Defecation ```

Question 61

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

Answer 61

Duodote

Question 62

Antidote for animal bites

Answer 62

Rabies vaccine + Human rabies immune globulin

Question 63

Black Widow spider bites and scorpion sting antidote

Answer 63

Antivenim (specific to bite)

Question 64

Snake bite antidote

Answer 64

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