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NURS 428 - Critical Care > Class 4 (02|01|22) Toxicology - Overdose & Poisonings > Flashcards

Class 4 (02|01|22) Toxicology - Overdose & Poisonings Flashcards

1
Q

What are toxidromes?
What do they help with?
Is it a perfect science?

A

a group of clinical signs and symptoms associated with a toxic ingestion or exposure (often with overdosage)

Help with the identification of common signs and symptom pt are presenting with which help HCP determine the class of drugs uses 
Combination of specific signs and symptoms that reflect drug class effects on particular neuroreceptors

Imperfect because symptoms from multiple toxins can overlap, clouding the clinical picture

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2
Q

Toxidormes Classication

A

Downers
opioid
Sedative-Hypnotic
Cholinergic

Fast & Furious
Anticholinergic
Sympathomimetic

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3
Q

Downers — OPIOIDS

examples

A

Morphine, Codine, Tramado, Heroin, Meperidine, Diphenoxylate, Hydromorphone, Fentanyl, Methadone, Propoxyphene, Pentazocine, DXM, Oxycodone, Hydrocodone

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4
Q

Downers — OPIOIDS

pathophysiology

A

stimulate three receptors in the CNS and PNS

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5
Q

Downers — OPIOIDS

main use

A

MAIN USE: analgesic properties — inhibits nociceptive information in the nervous system (prevents transmission of pain to the brain
Euphoria — increases dopamine release
Anxiolysis — lower anxiety

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6
Q

Downers — OPIOIDS

s/s

A 
Heart Rate: decrease 
Resp Rate: decrease 
Temp: decrease 
Pupils: pinpoint/constricted 
Bowel sounds: decrease 
Skin: normal
Mental status: depressed
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7
Q

Downers — OPIOIDS

management

A

ABCDE approach
Naloxone-: block effect of opioid
Blood Glucose:hypoglycemia can present similarly
GI decontamination: risk for aspiration so a later resort

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8
Q

Downers — OPIOIDS

significant clinical findings

A

resp rate > 12 is usually the best indicator

Look for tach marks

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9
Q

Downers — SEDATIVE-HYPNOTIC

examples

A

Anti-anxiety agents, muscle relaxants, antiepileptics and preanesthetic medications -Barbiturates - Benzodiazepines

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10
Q

Downers — SEDATIVE-HYPNOTIC

treatment/managment

A

ABCDE approach — focusing on the life threatening aspects (cardio, resp depression)
Dialysis in order to clear the toxins
Flumazenil: Benzo - antagonist: blocks the effects of the benzodiazepines

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11
Q

Downers — SEDATIVE-HYPNOTIC

s/s

A 
Heart Rate: decrease 
Resp Rate: decrease 
Temp: decrease 
Pupils: no change 
Bowel sounds: decrease 
Skin: normal
Mental status: depressed
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12
Q

Downers — SEDATIVE-HYPNOTIC

useages

A

Choral hydrate: sedation in hospital

Rohypnol: date-rape-drug (gamma hydroxybutyrate)

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13
Q

Downers — SEDATIVE-HYPNOTIC

patho

A

enhance the effect of the GABA transmitter that blocks impulse nerve cells and brain
Increase GABA/blockage, they can improve mood and anxiety
When taxes in excess, end up with toxidrome: sedative and hypnotic

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14
Q

Downers — SEDATIVE-HYPNOTIC

what present similarly

A

signs and symptoms of the over dose can look like alcohol usage

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15
Q

What is Flumazenil?

A

Flumazenil: Benzo - antagonist: blocks the effects of the benzodiazepines (Downers — SEDATIVE-HYPNOTIC)

Antagonsis

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16
Q

Downers — CHOLINERGIC

examples

A

Organic Phosphorous Compounds: Carbamates, Arecholine, Pilocarpine, Urecholine (Betanechol), Carbachol, Choline, Metacholine, Mushrooms

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17
Q

Downers — CHOLINERGIC

common uses

A

found in agriculture and chemicals

Included in medications

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18
Q

Downers — CHOLINERGIC

patho

A

increase levels of acetylcholine at the neuromuscular junction due to the inactivity of the acetylcholine enzyme which would normally break down acetylcholine
Results with increase levels and longer duration at the receptor of acetylcholine
Symptoms arise when the receptors found: smooth muscle of GI, bronchi, heart, salivary & sweat glands, and ciliary body of eye

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19
Q

Downers — CHOLINERGIC
“classic” set of s/s
SLUDGE

A 
Increase salivation and sweating 
increase lacrimation
increase urinary incontinence 
increase diarrhea
increase GI cramps
increase emesis
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20
Q

Downers — CHOLINERGIC

s/s

A 
Heart Rate: no change - decrease 
Resp Rate: no change 
Temp: no change  
Pupils: pinpoint/constricted 
Bowel sounds: increase
Skin: diaphoresis 
Mental status: depressed, confused, seizures
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21
Q

Downers — CHOLINERGIC

treatment/management

A
  • anticholinergic medications: atropine (IV) | diazepam: treat seizures
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22
Q

Fast & Furious — ANTICHOLINERGIC

examplese

A

Anticholinergics - Atropine, scopolamine, glycopyrrolate benztropine, trihexyphenidyl
Antihistamines - chlorpheniramine, cyproheptadine, doxylamine, hydroxyzine, dimenhydrinate, diphenhydramine, meclizine promethazine

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23
Q

Fast & Furious — ANTICHOLINERGIC

common uses

A

Tricyclic antidepressants, muscle relaxants, anti-psychotics, antimuscarinic agents for an overactive bladder (Oxybutlnin)
Plants

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24
Q

Fast & Furious — ANTICHOLINERGIC

patho

A

inhibition of the muscarinic cholingeric neurotransmission: block the acetylcholine from blinding to receptors (blocks parasympathetic nervous system and body will enter fight to flight mode with no regulation)
Reports can be found on the smooth muscle on the Gi tract, bladder, heart, sweat glands, ciliary of eye, salivary glands

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25
Q

Fast & Furious — ANTICHOLINERGIC

s/s

A 
Heart Rate: increase 
Resp Rate: no change 
Temp: increase  
Pupils: dilated 
Bowel sounds: decrease 
Skin: normal - dry
Mental status: depressed, confused, hallucinations, seizures
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26
Q 
Fast & Furious —  ANTICHOLINERGIC
memorization technique (5)
A 
Mad as a hatter - altered mental status 
blind as a bat - mydriasis 
red as a beet - flushed skin 
hot as a hare - skin dry 
dry as a bone - dry mucous membranes
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27
Q

Fast & Furious — ANTICHOLINERGIC

significant clinical findings

A

body cannot sweat so it regulates body temp by becoming hyperthermic
Tachycardia: earliest and most reliable s/s

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28
Q

Fast & Furious — ANTICHOLINERGIC

treatment

A

ABCDE approach:
Gastric decom. : activated charcoal
Diazepam: calm, treat seizures
Physostigmine salicylate: antidote for anticholingeric toxicity

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29
Q

What is physostigmine salicylate?

A

Physostigmine salicylate: antidote for anticholingeric toxicity

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30
Q

Fast & Furious — SYMPATHOMIMETIC
examples
where is it found in medication?

A

Caffeine, cocaine, amphetamines, methamphetamines, ritalin, LSD, Theophylline, MDMA

Medication: E, NE, dopamine

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31
Q

Fast & Furious — SYMPATHOMIMETIC

patho

A

CNS stimulation increase because increased circulating levels of catecholamines (E/NE and dopamine)
Causes reduced catecholamine re-uptake at the pre-ganglionic synapse (body in fight or flight and unable calm itself down)

32
Q

Fast & Furious — SYMPATHOMIMETIC

s/s

A 
Heart Rate: increase  
Resp Rate: increase 
Temp: increase 
Pupils: dilated
Bowel sounds: increase 
Skin: diaphoresis
Mental status: alert, agitated, seizures
33
Q

Fast & Furious — SYMPATHOMIMETIC

significant clinical findings

A

hyperthermia here can result in rhabdomyolysis and brain injury acidosis and essentially disseminated intravascular coagulation — life-threatening cerebral hemorrhage
Agitation, psychosis, seizures, responsive dilated pupils
Can lead to excited delirium
COMMON causes of death: intracerebral haemorrhage, hyperthermia and arrhythmias (VIA acidosis, tachycardia and hypertension)

34
Q

Fast & Furious — SYMPATHOMIMETIC

treatment

A

ABCDE approach
Hyperthermic: cool, ice packs, fans, Cooling blanket
Hypertension: nipride- potent vasodilator (IV)
Diazepam: slow body down and help control seizures

35
Q

Using toxidromes, what should be assessed/affect the airway?

A

Look for signs of inability to protect airway (secretions, vomiting)
LOC decreased to the extent of unable to protect airway
GCS comma scan <8
Implement interventions if needed

36
Q

Using toxidromes, what should be assessed/affect the breathing?

A

(Rate, Depth)

- intervene: beg valve mask ventilation, O2

37
Q

Using toxidromes, what should be assessed/affect the circulation?

A

Careful attentions to colour of skin and diaphoresis/dryness

38
Q

Using toxidromes, what should be assessed/affect the disability?

A

GCS: responsive, unresponsive
Pupils
Movement of extremities
Glucose: s/s can mimic hypoglycaemic

39
Q

Using toxidromes, what should be assessed/affect the Elimination/Exposures?

A 
Remove clothing 
Transdermal patches
External contaminants: substance on clothing or personal 
Measure temp
Look for tack marks 
Skin infections
40
Q

What does the following diagnostic testing indicate?
blood glucose
CBC, electrolytes
BUN/Cr

A

Blood glucose: baseline, rule out hypoglycaemia
CBC, electrolytes: baseline, risk of arrhythmias with certain toxins, fluid balance
BUN/Cr: evaluate the kidney function and the risk of rhabdomyolysis

41
Q

What is rhabdomyolysis?

A

rhabdomyolysis: when the skeletal muscle fibres begin to break down and the muscle content leak into circulations (can happen in certain toxin overdoses

42
Q

What does the following diagnostic testing indicate?
liver enzymes
INR/Ptt
Serum osmolality

A

liver enzymes: want baseline for liver function, determine if there abnormalities to make it difficult to excerpt toxin
INR/Ptt: asses risk increase risk of bleeding
Serum osmolality: what substance are dissolved in our blood; sodium glucose and urea are primary substance

43
Q

What does the following diagnostic testing indicate?
Lactate
Urinalysis
Beta-HCG

A

Lactate: acidotic determine through arterial blood gas
urinalysis: aspirin overdose - help determine treatment to affect the alkalinization of the urine
Beta-HCG: pregnant

44
Q

What does the following diagnostic testing indicate?
Troponin
CK
Tox Screen

A

Troponin: myocardial damage
CK (creatinine kinase: skeletal muscle damage
Tox screen: Serum (ASA, alcohol, acetaminophen etc) and urine — help determine how much is in the system or how much has been eliminated

45
Q

Using toxidromes, what should be done for management for airway?

A
  • intubate if not protecting airway (GCS >8)
46
Q

Using toxidromes, what should be done for management for breathing?

A

provide oxygen and respiratory support as needed

Respiratory support: mechanical ventilation, beg valve mask ventilation

47
Q

Using toxidromes, what should be done for management for circulation?

A

vascular access: IV
IV fluids/pressors as needed: rehydrate to clear toxins, if BP is low
Insert folet

48
Q

Using toxidromes, what should be done for management for Disability?

A

treat hypo/hyperglycemia if present

49
Q

Using toxidromes, what should be done for management for Elimination/exposures?

A
  • remove clothing transdermal patches, external contaminants
50
Q

What can be done to manage to reduce absorption with drug toxicity?

A

Gastric decontamination

51
Q

Describe Gastric decontamination

A

REDUCING ABSORPTIOM
activated charcoal is a special form of carbon that can bind other substances on its surface
Used to absorb drugs in the GI tract to reduce absorption (VIA drink or nasal gastric tube)
Advers effects: nausea, vomiting

52
Q

what can be done to manage to reduce metabolism with drug toxicity?
examples (4)

A

Antidote or competitive inhibitors

Narcan (Naloxone)
Flumazenil (benzodiazepine antagonist/antidote: sedative-hypnotic)
Physostigmine (anticholinergic antidote)
Atropine (cholinergic antidote)

53
Q

Describe the mechanism of action of the competitive inhibitor Narcan (Naloxone).

A 
Opioid antagonist (VIA competes the receptor site so opioid cannot  but uptake) - nasal spray or injection (IM/SC) 
Only works w opioids
54
Q

Describe the mechanism of action of the competitive inhibitor Flumazenil (benzodiazepine antagonist/antidote)

A

Flumazenil (benzodiazepine antagonist/antidote): compete for the receptors

55
Q

Describe the mechanism of action of the competitive inhibitor Physostigmine (anticholinergic antidote)/

A

reverse the effects of the anti-cholinergic by increase the level of acetylcholine at the site of transmission (IV, IM)

56
Q

Describe the mechanism of action of the competitive inhibitor Atropine.

A

competitive antagonist of muscarinic receptors - competitive inhibition of the postganglionic acetylcholine receptors which leads to the parasympathetic inhibition of the acetylcholine receptor in the smooth muscle
IV, subQ, endotracheal tube, IM

57
Q

Using toxidromes, what examples for management for elimination? (4)

A

Alkalinization of the blood or urine
Hydration (IV fluids)
Hemodialysis
saline diuresis

58
Q

In management of drug toxicity, how does Alkalinization of the blood or urine work?

A

Alkalinization of the blood or urine: alter the urine pH to increase excretion
Sodium bicarbonate: pH >7.5 allows more drug to be excrete through the urine (used in aspirin OD’s)

59
Q

In management of drug toxicity, how does Hydration (IV fluids) work?

A

Hydration (IV fluids): increases volume of urinary fluids

60
Q

In management of drug toxicity, how does

A
61
Q

When is hemodialysis commonly used?

A

Common: alcohol, ethylene glycol methanol OD’s, lithium, acetaminophen, aspirin, dilantin

62
Q

In management of drug toxicity how does saline diuresis work?

A

patient dehydrated where admin of fluid will increase excretion of the toxin/substance

63
Q

How are Antihypertensives used to manage overdoses?

A

Pt presenting with sympathomimetic toxidromes - hypertension is common
Nipride

64
Q

What are the s/s of the first phase of Acetaminophen Overdose?

A 
1st 24 hours
S/s not specific
n/a
unwell
asymptomatic
65
Q

What are the s/s of the second phase of Acetaminophen Overdose?

A

24-72 hours (1-3 days)
Elevation in liver function test: AST & ALT, billrium, prothrombin time
Right upper qua pain

66
Q

What are the s/s and time period of the third phase of Acetaminophen Overdose?

A

72-96 hours (3-5 days)
Liver becomes necrotic: s/s liver dysfunction
Hepatic encephalopathy: VIA ammonia level increasing
Bleeding
Hypoglycemia

67
Q

What are the s/s and time period of the fourth phase of Acetaminophen Overdose?

A

5-7 days
Complete resolutions if damage cause is reversible OR
Liver transplant

68
Q

What is the treatment of Acetaminophen Overdose?

A

Treated with NAC (w in 8 hours)
N-acetylcysteine (Parvolex/Mucomyst)
Administered intravenously
Not an antidote but interferes with the binding to reduce absorption and metabolism of the drug

69
Q

Describe Acetaminophen Overdose — Pathophysiologic Effects.

A 
Acidic environments (stomach) allow for more drug absorption compared with tissue at a hight pH 
May cause spasm of pyloric sphincter 
Small amount excreted unchanged in urine
70
Q

What significant parts of the body does Salicylate Overdose affect?

A

It is an acid to when there is an overdosage, it ends up effecting the cardiac myocardial function which contributes to toxicity
Acid environment of stomach aids absorption (food delays absorption)

71
Q

What are the early symptoms of a Salicylate Overdose?

A

Nausea
Vomiting
Dizziness
Tinnitus: ringing in ears

72
Q

What symptoms indicate moderate toxicity in Salicylate Overdose? (>250mg/kg)

A 
tachypnea 
Hyperpyrexia 
Sweating 
Dehydration 
Agitation 
Ataxia 
Restlessness
73
Q

What symptoms indicate severe toxicity in Salicylate Overdose? (>500mg/kg)

A 
hypotension 
Metabolic acidosis
Cerebral edema
Oliguria 
Renal failure 
Coma
Seizure 
Acidosis can cause cardiac dysrhythmias and cardiac failure
74
Q

Describe the impact Salicylate Overdose has on the body. (resp, blood glucose, cerebral edema, cardiac, kidneys)

A

respiratory: respiratory alkalosis
Glucose homeostasis affected: interference of the KREB’s cycle (glycogen depleted results with low serum glucose levels)
Cerebral edema: increase
Myocardial depression and hypotension from the increasing acidic
Kidneys eliminate HCO3-, Na+ and K+: bc of increase acidosis
Need to admin electrolytes to stabilize ^

75
Q

What are the 6 phases of a basic approach to a poisoned patients?

A

(1) immediate assessment and stabilization
(2) laboratory assessment,
(3) decontamination,
(4) administration of an antidote,
(5) elimination enhancement of the toxin, and
(6) disposition

76
Q

What are the 5 basic intervention/management of a poisoned patient?

A

high flow oxygen for pt w suspected poisoning or ingestion and exhibit resp compromise
Blood glucose taken - hypoglycaemic 50mL of 50% dextrose
100 mg thiamine for Wernicke’s encephalopathy or alcohol use
Naloxone max 2 mg @ 0.1mg/kg
Seizure control - benzodiazepines & pyridoxine (vit. B6)

NURS 428 - Critical Care (10 decks)

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