ED 2 Toxicology Flashcards
what does the mnemonic MUDPILES stand for?
Methanol Uremia DKA Propylene Glycol Infection/Isoniazid (TB drug) Lactic Acidosis Ethylene glycol/ethanol Salicylates
which 2 key features will clue you into an aspirin overdose?
Kussmal breathing
Tinnitus
serum levels of what level represent potentially life threatening aspirin toxicity?
over 500 mg/kg
what lab values will change first with aspirin ingestion?
LFT
how often should you draw serum salicylate levels when monitoring potential overdose? why?
every 2 hours in acute, single dose OD
we don’t know when the full impact will be
at ____ hours post ingestion, your patient likely has fully absorbed the ASA
6 hours
careful with serum levels less than 6 hours post ingestion
what lab is essential to order in an ASA overdose? why?
arterial blood gases
will often see sever metabolic acidosis
what are the two treatments of choice in aspirin overdose?
DIALYSIS
alkalinize urine to 7.5-8 (give bicarb)
when can you perform gastric lavage in an ASA overdose until?
60 minutes post ingestion
someone correct me i wasn’t listening and i don’t know if we still do this
what is the max daily dosage for an adult taking acetaminophen?
4 grams
why do children under 5 fare better in terms of acetaminophen overdose?
they have more glutathione in their liver
describe the symptoms seen in phase 1 of acetaminophen OD. how long will these occur for?
asymptomatic to N/V, subclinical bump in LFT
lasts 0-24 hours
describe the symptoms seen in phase 2 of acetaminophen OD. how long will these occur for?
RUQ pain, N/V, continued increase in LFT
18-72 hours
describe the symptoms seen in phase 3 of acetaminophen OD. how long will these occur for?
jaundiced, coagulopathy, liver necrosis, renal failure, fatality
72-96 hours
what is the KEY thing to keep in mind when worrying about an acetaminophen overdose?
these patients will get sick DAYS later
when do you draw levels when monitoring an acetaminophen overdose?
immediately and at 4 hours
when does max absorption of acetaminophen occur?
4 hours
what level should you draw continuously throughout a patient’s stay to monitor mortality in a suspected acetaminophen overdose?
lactate level
how should ABG of an acetaminophen overdose look?
normal! normal pH
if its not normal, assume other ingestion
what is the TOC for acetaminophen overdose? when should you give it by?
n-acetylcystine loading and maintenance dose
give within 8 hours or ANYTIME when pregnant
what are the 4 criteria for liver transplant in an acetaminophen overdose?
1) pH less than 7.3
2) grade 3+ encephalopathic
3) PT greater than 100
4) serum creatinine over 3.4
who do we use the rumack-matthew nomogram for?
tool to monitor probable acetaminophen serum levels vs. time in our OD patient
patient presents with tremor rigidity, hyperreflexia, anxiety, and agitation. you suspect serotonin syndrome – what levels should you draw?
creatinine kinase levels to check for rhabdomyolysis
how do we treat serotonin syndrome?
benzodiazepines
BP control
fluid for rhabdomyolysis control
cooling
when is peak absorption for tricyclic antidepressants? what is a toxic dose?
peak absorption 1 hour
toxic dose 10-20mg/kg
most common TCA that we see overdose in? who should you avoid this med in?
amitriptyline
avoid in pt with uncontrolled mental illness or HX of suicide attempts
what signs should make you worry about impending TCA overdose?
anticholinergic toxidrome
hyperthermia, confusion, dry mouth, urinary retention, grabbing invisible objects, dilated pupils, flushed skin, tachycardia, shaking
what does the SALT toxidrome of TCA overdose look like?
shock
altered mental status
wide QRS
terminal R wave in AVR
what is the TOC for TCA overdose?
give bicarb until serum pH is 7.4+
intubation in severe OD: can hyperventilate patient on vent!
which three ODs cause severe metabolic acidosis?
ethylene glycol, TCA, ASA
TCA overdose will be initially _____ but will crash very shortly after
initially asymptomatic
when is the peak effect with the following routes of opiate administration?
1) IV
2) IM
3) PO
IV: 10 minutes
IM: 30-45 minutes
PO: 90 minutes
which routes of ingestion do we worry most about with opiate overdose, as they are very hard to control with narcan?
dilaudid and methadone (long acting)
narcan’s half life is very short
key finding of opiate overdose?
respiratory depression, bradypnea, hypoxia
should NOT see cardiac issues unless down for a LONG time
what lab should you draw in any patient who presents to the ER unresponsive?
finger stick blood sugar
_____ promotes aggression and may require restraining the patient upon administration
narcan
if your patient had an oral OD of opiates, what should you consider?
GI decontamination
if opiate OD patient is still altered after administration of narcan, what must you assume?
other ingestion vs. anoxic brain injury
OD on CCB verapamil will cause what two physiologic responses?
vasodilation (hypotension) and bradycardia
which verapamil formulation is most dangerous? how will these patients present?
extended release – VERY sick, one of worst ODs you will see
onset of OD overdose in verapamil?
15 minutes - 2 hours
OD with over 1 gram
what are the 3 treatments you give for verapamil overdose?
1) CaCl 10 percent
2) pacing
3) pressor support
which substance is relatively benign until it is metabolized into glycolic acid?
ethylene glycol
how will an ethylene glycol OD present?
1) initially no abnormalities
2) altered mental status
3) kussmal breathing
4) very sick
what should your workup of your ethylene glycol OD consist of?
look at serum osmolality vs. calculated anion gap
serum osmol should be equal to calculated osmol, if its not you’re in trouble
what is the conversion factor for ethylene glycol?
6.2
what is the treatment of choice for ethylene glycol overdose?
1) bicarb to correct acidosis (7.4+)
2) fomepizole TOC
3) end game is dialysis
