Clinical Toxicology II

Question 1

Case 4: A 16 year old female is brought into the emergency room by her parents. They report that they found her in her room when they arrived home. She appeared very drowsy. An empty bottle of medicine was found by her bed.
Past med history - None
Medications - None, Allergies - None

Answer 1

Physical Exam - Screaming 16 year old
BP 160/100,
Pulse 136, 
RR 18, 
Temp 101 (not sweating)

Eyes pupils markedly dilated and sluggish. Dry mucous membranes, hypoactive bowel sounds, Skin Red warm and dry
Mental status
disoriented, combative with no focal deficits (mad as a hatter)

She is in anticholinergic

Question 2

Antihistamine (Diphenhydramine) overdose presents similar to Anticholnergic. So what is the solution?

Answer 2

Physostigmine (an anticholinesterase) –increases acetylcholine at the receptor to mitigate the anticholinergic effects at the receptor.

Question 3

You have to be careful with giving Physostigmine to patients who are taking TCA

Answer 3

• Tachycardia

- not in a dehydrated cocaine patient —> seizures if to high and too rapidly

Question 4

In which patient population is Physostigmine?

Answer 4

Pure anticholinergic poisoning (good Hx)
Central nervous system manifestations
Peripheral nervous system manifestations
No ECG findings suggesting TCA exposure (no axis deviation)

Question 5

Case 5: A gardener is found on the front lawn writhing, in vomit, and having diarrhea. He is not oriented and is sweating profusely.

Answer 5

Cholinergic poisoning - wet everywhere
(Salivation, Lacrimation, Urination, Defecation)
**organophosphates

Question 6

How do you treat pesticide overdose?

Answer 6

Atropine - to treat the wet effect - A TON

Pralidoxame (2-PAM) -for nicotinic effects, an enzyme regenerator

Question 7

Case 6: A 42 year old male is brought into the emergency room by friend from the rescue mission. The friend reports that the patient was binge drinking last night. The patients friend states that he has seen him drunk plenty of times, but he appears more ill then ever before. He found an empty bottle of windshield wiper fluid next to his bed.
Past med history - Alcoholism
Medications - ?, Allergies - ?

Answer 7

VS: P 120, BP 130/80, RR 28, T 95
HEENT - Pupil 4mm sluggishly reactive to light,
Neuro: non-focal, withdraws from pain, mumbles incoherently when asked questions

ETHYLENE GLYCOL POISONING –> Metabolic Acidosis kills!
osmolar gap> 50 = Toxic Alcohol

Question 8

What is the treatment of toxic alcohol poisoning?

Answer 8

Hemodialysis (to clear acids) and FOMEPAZOLE- which blocks the metabolism of methanol (from windshield wiper fluid)

Question 9

Case 7: A 14 year old female is brought into the emergency room by her parents. She admitted to taking her grandfather’s blood pressure medicines approximately 2 hours prior to coming to the ER.
Past med history - None
Medications - None, Allergies - None
Then she becomes

Answer 9

Antihypertensive that causes bradycardia AND hypotensive at the same time===> Calcium Channel Blocker (Nifedipine and Dihydropyridines)

Question 10

How do you treat CCB-an antihypertensive overdose?

Answer 10

• IV fluids, decrease absorption (charcoal and whole bowel irrigation)
• GLUCAGON
• INSULIN- High dose
• Calcium salts
• vasopressors

Question 11

Case 8: Digoxin Toxicity - increases intrcelluar Ca which increases contractility and increases BP. In toxicity it causes hyperkalemia (from muscle groups). HYPERKALEMIA kills you!

What is the antidote?

Answer 11

Digibind

Question 12

Case 9: Cocaine/Synthetic Marijuana/Marijuana/ LSD Toxicity - an upper

What is the treatment?

Answer 12

“uppers” - high BP, HR, increase NE, Epi - RED eyes

Treatment is sedation (Diazepam), restraint, cooling