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Critical Care Test #3 > Drug Overdose and Poisoning #2 > Flashcards

Drug Overdose and Poisoning #2 Flashcards

1
Q

Describe carbon monoxide.

A

colorless, odorless gas that has a 200x more affinity for hemoglobin than oxygen.

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2
Q

What are some sources of exposure to carbon monoxide?

A

car exhaust

natural gas

propane furnace emissions

cigarette smoke

wood stove emissions

pollution

kerosene

charcoal

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3
Q

What are some signs of carbon monoxide posioning?

A

flu-like symptoms - HA dizziness, n/v

Increased exposure: dyspnea, AMS, coma, seizures, respiratory arrest

cv: chest pain (ischemia), dysrhythmias, hypotension, cardiac arrest

Renal: renal failure from rhabdo due to to prolonged unconsciousness has occured

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4
Q

How do you diagnose carbon monoxide poisoning?

A

Carboxyhemoglobin levels (COHb)

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5
Q

What is the fetal COHb in comparison to maternal?

A

10-15% greater

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6
Q

What level diagnoses carbon monoxide poisoning in a smoker and non-smoking patient?

A

> 10% in smoker and > 5% in non-smoker

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7
Q

Obviously to prevent further absorption you remove the patient from the source of the gas, how is it further treated after this is done?

A

ABCs

100% oxygen

If severe (decreased LOC, cerebellar dysfunction, COHb >25%: HBO therapy

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8
Q

What are some examples of prescribed and recreational opioids?

A

Prescribed: norco, lortab, oxycodone, oxycontin

Recreational: abuse of prescribed, heroin, morphine

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9
Q

What are the most common signs and symptoms of an opioid/benzo overdose?

A

CNS depression

miosis (pupil constriction)

respiratory depression

hypothermia

bradycardia

respiratory arrest = death

pulmonary edema

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10
Q

What are the proper interventions for an opioid overdose?

A

ventilation and nalaxone

for the client that requires multiple doses, an infusion should be administered because of its short action

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11
Q

what are the proper interventions for a benzodiazepine overdose?

A

ventilation and flumazenil

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12
Q

when is flumazenil indicated?

A

in a client who is benzo naive, quick reversal may cause seizures or status epilepticus in benzo dependent clients

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13
Q

What are some signs and symptoms of a cocaine overdose? What about crack cocaine (smokable)?

A

cocaine: wide QRS and prolonged QT intervals, can be myocardial toxic in large doses, dysrhythmias, myocarditis, cardiomyopathy, myocardial ischemia and infarct, aortic rupture, aortic and coronary artery dissection.

RHABDO

Crack cocaine: pulmonary hemorrhage, pneumonitis, asthma, pulmonary edema, pneumomediastinum, pneumothorax, pneumopericardium

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14
Q

What are some signs and symptoms of a methamphetamine overdose?

A

hyperthermia, dysrhythmias, seizures, HTN, intracranial hemorrhage or infarction, rhabdo

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15
Q

How do you treat cocaine, amphetamine, and other stimulant overdose?

A

sedations and vitals assessment, ECG

Cardiac enzymes to rule out MI

active cooling

treat seizures with benzos, phenobarbital if not effective

treat cardiac ischemia with chest pain protocols

people who pack the drugs in their system but are asymptomatic should be treated with activated charcoal

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16
Q

What are the signs and symptoms of ASA toxicity?

A

Neuro: tinnitus, lethargy, confusion, seizures, cerebral edema

Respiratory: tachypnea, pulmonary edema, respiratory alkalosis coupled with metabolic acidosis

GI: n/v, GI hemorrhage, hypothrombinemia, platelet dysfunction

Renal: dehydration, hypokalemia

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17
Q

How do you treat ASA poisoning?

A

prevention of absorption: syrup of ipecac, gastric lavage, activated charcoal

IV hydration

sodium bicarb if needed

potassium replacement if needed

hemodialysis if in renal failure

supportive care

monitor for cerebral edema

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18
Q

What lab tests would be assessed in ASA poisoning?

A

salicylate level, serial electrolytes, ABGs, coagulation studies

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19
Q

Describe what would be seen in an acetaminophen toxicity day by day starting day 1 going through day 4.

A

day 1 - may be asymptomatic, anorexia, nausea, malaise

day 2-3 - n/v, abdominal pain with elevated liver function tests and bilirubin possible, PT increase

day 3-4 - fulminant hepatic failure with lactic acidosis, coagulopathy, renal failure, and encephalopathy, jaundice present

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20
Q

How long after ingestion and how long after first level should serum acetaminophen levels be drawn?

A

4 hours - first draw or later if patient present to facility at later time

draw every 4 hours for 24 hour

21
Q

What is the treatment for acetaminophen overdose?

A

activated charcoal. acetylcysteine (mucomyst), liver transplant center

22
Q

What are the protocols for oral and IV acetycysteine?>

A

Oral: NAC, mucomyst

  • 140mg/kg loading dose
  • 70 mg/kg every 4 hours for total of 17 maintenance doses
  • dilute NAC (20% solution) with soft drink or juice
  • repeat any dose not tolerated after 1 hour, antiemetics may be needed to control vomiting

IV: acetadote

  • 150 mg/kg in 200ml of D5W loading dose over 60 minutes
  • first maintenance dose of 50 mg/kg in 500ml of D5W over 4 hours
  • second maintenance dose of 100mg/kg in 1000 ml of D5W over 16 hours
23
Q

describe the three phases of antifreeze/ethylene glycol overdose and the time frame of each phase.

A

1 - within 12 hours of ingestion - dominate CNS effects, client may appear intoxicated minus the smell of ETOH on the breath.

2 - 12-24 hours of ingestion - cardiopulmonary effects dominate - increased HR, increase RR, increase BP, CHF, respiratory distress, circulatory collapse

3 - within 24-72 hours of ingestion - renal effects predominate - flank pain, acute tubular necrosis, renal failure

24
Q

How do you treat an ethylene glycol/antifreeze overdose?

A

fomepizole - inhibits alcohol dehydrogenase

ethanol drip - inhibits formation of toxic metabolites becuase it has a 10-20 times greater affinity for alcohol dehydrogenase than methanol and a 100 times greater affinity than ethylene glycol

even using oral commercial alcoholic beverages may be indicated

monitor serum glucose - energy is used in metabolism of toxin, reduces BG

possible dialysis

25
Q

What does MUDPILES stand for, and what exactly is it?

A 
Methanol
Uremia
DKA
Paraldehyde
Iron, Isoniazid, Inhalants
Lactic acidosis
Ethanol, Ethylene glycol
Salicylates

This is a ddx for high anion gap metabolic acidosis

26
Q

What are some examples of anticholinergic substances?

A 
antihistamines
anti-parkisonian agents
antipsychotics
antispasmodics
TCAs
OTC meds: excedrin PM, corocidin
skeletal muscle relaxants
mushrooms/plants
27
Q

What are some signs and symptoms of anticholinergic toxicity?

A 
mydriasis
HTN
hypoactive or absent bowel sounds
tachycardia
flushed skin
disorientation
urinary retention
hyperthermia
dry skin and mucous membranes
confusion and agitation
auditory and visual hallucinations
28
Q

How would you diagnose an anticholinergic overdose?

A

CLINICAL S/S

Labs are usually normal and toxicology screens are of little to no value

29
Q

How do you treat an anticholinergic overdose?

A

Monitor for tachycardia and dysrhythmias

gastric lavage if within 1 hour of ingestion

activated charcoal

monitor for hyperthermia

monitor for seizures

30
Q

When does serotonin syndrome most commonly occur?

A

THERAPEUTIC DRUG LEVELS

31
Q

What is serotonin syndrome?

A

Rare, idoiosyncratic compilation of antidepressant therapy characterized by cognitive impairment and autonomic neuromuscular dysfunctions

32
Q

How is serotonin syndrome caused?

A

May be caused by any drug combination that increases central serotonin transmission

33
Q

What are some cognitive and behavioral findings associated with serotonin sickness?

A 
confusion
agitation
coma
anxiety
hypomania
lethargy
seizures
insomnia
hallucinations
dizziness
34
Q

What are some autonomic signs of serotonin syndrome?

A 
hyperthermia
diaphoresis
flushed skin
sinus tach
HTN
tachypnea
dilated or unresponsive pupils
hypotension
diarrhea
abdominal cramps
35
Q

What are some neuromuscular findings associated with serotonin syndrome?

A 
myoclonus
hyperreflexia
tremors
muscle rigidity
babinski sign
nystagmus
trismus (lockjaw)
36
Q

How do you treat serotonin syndrome?

A

discontinue serotoninergic agents

benzo to relieve muscle cramping and rigidity

monitor for rhabdo and/or metabolic acidosis

ADMIT THE PATIENT

37
Q

What are some examples of TCAs?

A 
Amitriptyline (Elavil)
Amoxapine (Asendin)
Clomipramine (Anafranil)
Cyclobenzaprine (Flexeril)
Doxepin (Adapin/Sinequan)
38
Q

What are TCAs used for? Has the popularity increased or decreased over the years?

A

depression

decreased

39
Q

What age do most TCA exposures occur? What percentage is intentional?

A

young adults

60%

40
Q

What are some signs and symptoms of mild TCA toxicity?

A 
Drowsiness
confusion
slurred speech
ataxia
dry mucous membranes and axcillae
sinus tachy
decreased bowel tones and ileus
mild HTN (doesnt usually require treatment)
hypotension
41
Q

What are the S/S of severe TCA toxicity? What time frame is this usually seen after ingestion?

A

Usually seen within 6 hours of ingestion?

coma
cardiac conduction delays
SVT
VT 
seizures
42
Q

What are some secondary isues that can be caused by TCA toxicity?

A

pulmonary edema
anoxic encephalopathy
hyperthermia
rhabdo

43
Q

How do you treat TCA toxicity?

A

secure airway if needed
IV, IVF hydration
continuous cardiac monitoring
seizure precautions’
urinary catheter for antimuscarinic symptoms (unrinary retention)
if early ingestion activated charcoal is indicated

44
Q

What triage level would some with TCA toxicity be?

A

Level 2 (RED)

45
Q

What labs would you mintor with TCA toxicity?

A

electrolytes
CK
ABG
TCA drug screen (toxicology screen)

46
Q

If the TCA ingestion was intentional and toxic what also may be needed as far as assessment?

A

psychiatric admission and assessment

47
Q

If the clients toxicity was unintentional and becomes asymptomatic for 6 hours is it okay to discharge them?

A

YES

48
Q

Who is always contacted in TCA overdose?

A

POISON CONTROL

Critical Care Test #3 (6 decks)

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