clinical toxicity I and II

Question 1

what is the toxicidrome for opioids?

Answer 1

altered mental, decreased RR, decreased HR, BP, temperature, pinpoint pupils and decreased bowel sounds.

Question 2

what are some common opioids

Answer 2

heroin, fentanyl, codeine, hydrocodone, meperidine, oxycodone, methadone

Question 3

what to give in a opioid scenario

Answer 3

ABC/substrates. remove all obstructive process, assess and protect if necessary, IV fluids, O2 100%, dextrose/thiamine.

Question 4

what drug can reverse an opioid OD

Answer 4

naloxone. competitive mu/delta/kappa antagonist. can precipitate withdrawal.

Question 5

are higher or lower doses of naloxone needed for synthetic opioids

Answer 5

higher,

Question 6

what are some natural opioids

Answer 6

morphine, codeine

Question 7

what are some semi-synthetic opioids

Answer 7

heroin, oxycodone, hydromorphone

Question 8

what are some fully synthetic opioids

Answer 8

meperidine, methadone, fentanyl.

Question 9

what is characteristic of opioid withdrawal

Answer 9

flu-like symptoms nausea, vomit, piloerection, yawning. normal mental status

Question 10

what are two other opioid reversal drugs

Answer 10

nalmefene and naltrexone

Question 11

benzodiazepam toxidrome

Answer 11

depressed mental status, normal vitals

Question 12

treatment for the benzodiazepam OD

Answer 12

supportive, ABCs, consider flunazenil

Question 13

what is flunazenil

Answer 13

competitive non-selective benzodiazepam antagonist. only works for benzodiazepam, not the other sedative-hypnotics

Question 14

do patients have to have a history of acetominophen ingestion to have a treatable level?

Answer 14

no. 1/500 w/o a history have a treatable level.

Question 15

stage 1 acetominophen toxidrome

Answer 15

0-24hrs GI irritation, generally asymptom.

Question 16

stage II acetominophen toxidrome

Answer 16

24-72 hours. LFT and renal function abnormalities, can have RUQ pain.

Question 17

stage III acetominophen toxidrome

Answer 17

72-96 hrs. hepatic necrosis, can also show renal failure

Question 18

stage IV acetominophen toxidrome

Answer 18

4days-2weeks. resolution of organ function

Question 19

what is antidote for acetominophen poisoning

Answer 19

N-acetylcysteine. best if given within 8 hours of overdosr.. it is effective for all stages of toxicity.

Question 20

when is NAC indicated for patients with acetominophen poisoning

Answer 20

a level unknown at the time of ingestion over the rumack-mathew nomogram. if the patient is showing signs og hepatotoxicity. when the APAP level will not be available within 8 hours of ingestion.

Question 21

what are the signs of late APAP toxicity

Answer 21

prothrombin time > 200, serum Cr > 3.3. hepatic encephalopathy, blood pH < 7.3, factor VIII/V ratio > 30

Question 22

what are two measures for the APAP toxicity that predict a poor prognosis

Answer 22

serum lactate elevation taken at various times throughout presentation. serum phosphate levels even more accurate. if the phosphate levels are elevated 2-3 days post OD >1.2 then that confers a poor prognosis

Question 23

what are the mechanisms of NAC

Answer 23

supplies sulfhydryl groups, antioxidant. improves microcirculation, supplies glutathione and has antiinflammatory properties.

Question 24

tricyclic antidepressants

Answer 24

anticholinergic, catechol reuptake inhibitors, alpha-adrenergic blocker, GABA antagonists, sodium channel blocker.

Question 25

what does the toxidrome for tricyclic antidepressant

Answer 25

elevated HR, widened pupils, dry mucous membranes, dry flushed skin, decreased bowel sounds.. (alpha-blockers can cause hypotension). widened QRS complex.

Question 26

what is the antidote for tricyclic antidepressant toxicity

Answer 26

sodium bicarbonate, the alkalinization reduces the affinity for the TCA for its receptor and the sodium overcomes the sodium channel inhibitions. must careful to monitor the EKG and the blood pH

Question 27

what is the anticholinergic toxidrome

Answer 27

mydriasis, dry-flushed skin, decreased bowel sounds, urinary retention, increased temperature, confusion, hallucination, seizures.

Question 28

what are some common anticholinergics

Answer 28

atropine, diphenhydramine, scopolamine, meclizine

Question 29

what is the antidote to anticholinergic

Answer 29

physostigmine -anticholinesterase.

Question 30

when is physostigmine contraindicated

Answer 30

when there is TCA exposure. it causes asystole. there is muscarinic and nicotinic excess seen when the patient has not been exposed to anticholinergics.

Question 31

what are the indications for using physostigmine

Answer 31

when there is pure anticholinergic, when there are CNS changes or peripheral, when there are no ECG findings suggesting that there is TCA exposure.

Question 32

what do we treat with when we are unsure that the patient has ingested an anticholinergic

Answer 32

sedative-hypnotics. diazepam works great

Question 33

what is the toxidrome for cholinergic

Answer 33

opposite of anticholinergic, miosis, salivation, bronchorrhea/spasm, fasciculations

Question 34

what are some cholinergics

Answer 34

anticholinesterases (nerve gases, organophosphates, carbamates, physostigmine, neostigmine). cholinomimetics such as bethanechol

Question 35

what is the antidote to cholinergic OD

Answer 35

atropine and some very high doses might be needed. pralidoxime which is an enzyme regenerator and reduces the excessive dosing of atropine.

Question 36

what is the differential when metabolic acidosis

Answer 36

MUDPILES methanol, uremia, diabetic ketoacidosis, paraaldehyde/metformin, iron, lactate, ethylene glycol, salicylate.

Question 37

what is the aim for treatment of methanol toxicity

Answer 37

to inhibit the ADH and then remove the toxic agent. usually given ethanol or fomepizole and dialysis..

Question 38

what is the indication for hemodyalysis

Answer 38

methanol or ethylene glycol level > 25-50, metabolic acidosis, coma, hemodynamic instability

Question 39

what is the differential for someone that is bradycardic and hypotensive

Answer 39

beta blockers, CCB, alpha-2 agonist, digoxin

Question 40

CCB toxidriome

Answer 40

peripheral vasodilation, decreased sinus rate, slows AV conduction. decreased pulse, BP. normal temp and respirations.

Question 41

is there increased or decreased ventricular contractility with CCB

Answer 41

decreased. it is a negative ionotrope.

Question 42

why is there is brady cardia when CCB toxic

Answer 42

there is sinus node depression due to the negative chronotropy

Question 43

what is the presentation of nifedipine and dihydropyridines toxicity

Answer 43

peripheral vasodilation, reflex tacycardia, there can hypotension.

Question 44

what is the presentation of verapamil or diltiazem OD

Answer 44

hypotension (vasodilation, bradycardia), bradycardia (inhibition of the sinus node

Question 45

what can be done for CCB OD

Answer 45

bowel irrigation, activated charcoal, IV, monitor

Question 46

what are some treatments for CCB OD

Answer 46

calcium salts, glucagon, amrinone, dopamine, dobutamine, norepinephrine, isoproterenol, insulin.

Question 47

what do B blockers do

Answer 47

negative inotrope/chronotrope, slow AV conduction. B(2) blockers cause bronchoconstriction and increased vascular resistance.

Question 48

what is important to know about BB at high doses

Answer 48

the selectivity is lost in OD

Question 49

what do BB do in OD?

Answer 49

mental status depression and seizures.

Question 50

what does clonidine do

Answer 50

alpha-2 agonist there is a decrease in CNS sympathometic output. cross-reactive with alpha-1

Question 51

what is the clinical presentation of clonidine OD

Answer 51

bradycardia, pinpoint pupils, CNS depression

Question 52

what is the predistribution digoxin toxicity

Answer 52

nausea, vomit, hyperkalemia

Question 53

what is the postdistribution digoxin toxicity

Answer 53

hypotension, bradycardia, arrhythmias, death

Question 54

what is the antidote for digoxin tox

Answer 54

digibind -an antibody that binds digoxin

Question 55

what is toxidrome for cocaine/amphetamines

Answer 55

CNS stimulation, agitation, hallucinations, seizures, increased muscle activity, temperature, CK, kidney injury. can cause decreased blood flow -angina, stroke, heart attacks.

Question 56

what are PCP/ketamine/DM, what do they do?

Answer 56

dissociative anesthetics. depending on dose: Low: euphoria medium: agitation, anesthesia, increased strength high: CNS anesthesia

Question 57

what can cause synthetic marjiuana cause

Answer 57

hyperadrenergic, seizures, paranoia

Question 58

what does LSD/psilocybin do

Answer 58

alters perceptions and hallucinations. psychiatric illness

Question 59

is LSD toxic

Answer 59

not inherently toxic. there are adverse effects related to experience

Question 60

what are downers?

Answer 60

GABA agonists such as GHB, roofies, etc.