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clin med > EM- toxicology/OD > Flashcards

EM- toxicology/OD Flashcards

1
Q

do you need to identify the poison before treating someone?

A

NO! Attempts to identify the poison should NOT delay care!

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2
Q

if someone has an altered mental status or depressed GCS, what three things can we give them?

A

the “coma cocktail” - DTN
D50 (for possible hypoglycemia)
thaimine (for possible alc. caused wernickes enceph.)
narcan aka naloxone (for possible opiod OD)

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3
Q

4 part general management for suspected overdose

A
  1. Ensure adequate airway: oral, nasal, intubate if necessary
  2. Ensure adequate oxygenation: high-flow O2, treat bronchospasm
  3. IV access: two large-bore lines
  4. Cardiac, VS & SpO2 monitor
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4
Q

what things can cause an altered mental status?

A

“AEIOU TIPS”
Alcohol, Endocrine, Epilepsy, Intoxication, Oxygen (hypoOx) , Uremia
Trauma, Tumor, Infection, Psychological, Shock, Stroke

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5
Q

Dx workup for suspected OD/tox?

A

labs: urine drug screen, CMP
imaging: Abdominal Xray
EKG: for conduction delays or ischemia

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6
Q

what is a toxidrome?

A

A collection of symptoms and signs that consistently occur after ingestion of a particular toxin or drug class or agent

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7
Q

how is a toxidrome Dx?

A

history and PE

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8
Q

5 classic toxidromes

A 
Sympathomimetic (cocaine, decongestants, MDMA, etc) 
Opiate
Anticholinergic
Cholinergic
Sedative-Hypnotic
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9
Q

what are the various mechanisms of sympathomimetic toxidromes?

A
  1. direct alpha & beta receptor agonists
  2. indirectly release catecholamines
  3. prevent metabolism & reuptake of catecholamines
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10
Q

what are the effects of a sympathomimetic toxidrome?

A

Increased temp, diaphoresis
Tachycardia & hypertension, Palpitations, chest pain
Mydriasis
CNS excitation, Hyperactivity, seizures

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11
Q

3 part txt for sypathomimetic toxidrome?

A

ABC
supportive care: lots of BENZOS!, temp control
consider GI decontamination
*txt HTN unresponsive to benzos

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12
Q

what are the 3 CNS receptors that opiods bind to? what are the effects of each?

A

Mu – analgesia, resp depression, euphoria
Kappa – sedation, analgesia, mioisis
Sigma – dysphoria, hallucinations

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13
Q

what are the effects of an opiate toxidrome?

A 
CNS depression & Respiratory depression
Bradycardia, Hypotension
Miosis
Hypothermia
Nausea/vomiting
Flaccidity
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14
Q

opiate toxidrome txt?

A

ABCs, supportive care, narcan!

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15
Q

what is the half life of narcan?

A

60-90 min in adults (shorter than opiod drugs)

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16
Q

what are the effects of an anti-cholinergic toxidrome?

A

“RED as a beet, DRY as a bone, BLIND as a bat, HOT as a hare, MAD as a hatter, FULL as a flask”

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17
Q

what is the antidote for anti-cholinergic toxidrome? when would you use it? why is this?

A

Physostigmine: ONLY if Severe agitation or psychosis unresponsive to other therapy
-NO history of seizures
-w/ normal EKG
-not on TCAs (b/c chol. syndrome)
why? Can cause cholinergic syndrome (if you go too far with txt)

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18
Q

these are all examples of what kind of toxidrome?
organophosphate & carbamate pesticides, nerve agents, edrophonium, pilocarpine, pyridostigmine
some ‘shrooms -muscarine containing

A

cholinergics

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19
Q

what are the effects of cholinergic toxidrome?

A 
D - diaphoresis, diarrhea, decr BP
U - urination
M - miosis
B - bronchorrhea, bronchospasm, brady
E - emesis, excitation of skeletal muscle
L - lacrimation
S - salivation, seizures
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20
Q

what is the pathophys of the cholinergic toxidromes?

A

Inhibition of acetylcholinesterase: leads to increased acetylcholine

Muscarinic activation
bradycardia, incr secretions, bronchospasm
Nicotinic
fasciculations, HTN, weakness

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21
Q

what antidote can you give for cholinergic toxidrome?

A

atropine (antichol)

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22
Q 
these are all what type of toxidrome? 
ETHANOL!!
anticonvulsants
barbiturates
benzodiazepines
GHB 
Ambien
A

sedative=hypnotics

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23
Q

what are the effects of sedative-hypnotic toxidrome?

A 
ataxia, decr reflexes, slurred speech, APNEA! 
confusion, sedation, coma
delirium, hallucinations
blurred vision/diplopia
dysesthesias/paresthesias
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24
Q

pathophys of sedative-hypnotic toxidromes

A

direct & indirect GABA agonists resulting in CNS inhibition

25
Q

sedative-hypnotic mgmt (4 step)

A
  1. ABC, supportive care
  2. Be prepared to intubate
  3. Activated charcoal
  4. No agent-specific antidotes. . . .except Romazicon® (flumazenil)
26
Q

when is the ONLY time you would use flumazenil? why?

A

if you caused the benzo-OD

- if benzos were not the causative agent, flumazenil can put them in status epilepticus

27
Q

what are the 4 general routes we can get rid of a poison ? what are these all trying to do?

A

Prevent or decrease further absorption
Increase elimination
Antagonize effects
*all trying to minimize the bioavailability

28
Q

what are the 4 general routes we can get rid of a poison ? what are these all trying to do?

A

Prevent or decrease further absorption
Increase elimination
Antagonize effects (antidotes)
*all trying to minimize the bioavailability

29
Q

how much charcoal do we give? when does it have the greatest effect?

A

1g/kg

greatest benefit within ONE HOUR of ingestion (effect is minimal after 2 hours b/c already passed the pylorus)

30
Q

when can you use gastric lavage?

A

ONLY if < 1 hour from ingestion and life-threatening drug or dose

31
Q

when would you use whole bowel irrigation on? who can’t you use it on?

A

Especially useful for metals or other things not well adsorbed by charcoal
Avoid in patients with obstruction or ileus

32
Q

what are 3 ways we decrease abs of a toxin?

A

charcoal, gastric lavage, whole bowel irrigation

33
Q

what are 2 ways we increase elimination of a toxin?

A
  1. alkaline/forced diuresis

2. extracorporeal removal

34
Q

what is is alkaline/forced diuresis? when is it used for toxin elimination?

A
  • infusion of LOTS of saline + bicarb
    Used to eliminate acidic drugs mainly excreted by the kidneys (salicylates, barbs, INH)
    *danger of serious fluid and electrolyte derangements
35
Q

what is extracorporeal removal?

A 
for active metabolites or poor organ clearance
will include…. 
Hemodialysis
Hemofiltration
Hemoperfusion
36
Q

what are the antidotes to these 3: Acetaminophen, Anticholinergics, Anticholinesterases?

A

Acetaminophen - N-acetylcysteine
Anticholinergics- physotigmine
Anticholinesterases - atropine

37
Q

what are the antidotes to these 3: Benzodiazepines

Carbon Monoxide, Cyanide?

A

Benzodiazepines- flumazenil
Carbon Monoxide- O2
Cyanide- amyl nitrite

38
Q

what are the antidotes to these 3: Benzodiazepines

Carbon Monoxide, Cyanide? (kinds weeds)

A

Benzodiazepines- flumazenil
Carbon Monoxide- O2
Cyanide- amyl nitrite

39
Q

what are the antidotes to these? Arsenic, copper, gold, lead, mercury (weeds)

A

Dimercaprol, EDTA, penicillamine

40
Q

what are the antidotes to these 2?Iron, Isoniazid (weeds)

A

Iron- Deferoxamine

Isoniazid- Pyridoxine

41
Q

what are the antidotes to these 4? Methanol

Methemoglobinemia, Opioids, Organophosphates (weeds)

A

methanol - Ethanol, fomepizole
metheblog.- Methylene blue
opiods- Naloxone
organophosphates- Atropine, 2-PAM-Cl

42
Q

what is the mainstay of most treatments for toxicology?

A

Supportive care and decontamination

43
Q

what is the toximetabolite of acetaminophen? what does it do?

A

Toxic metabolite NAPQ1

NAPQ1 binds to hepatocytes and causes necrosis

44
Q

acetaminophen toxic threshold in adults? what about ASA?

A

acetaminophen: Toxic threshold adults - 7.5-10g
ASA: Adult lethal dose - 10-30g

45
Q

acetaminophen poisoning signs: phase I < 24 hours

A

Anorexia, malaise, N/V, diaphoresis

46
Q

how many days after acetaminophen poisoning is hepatic and renal failure?

A

2-4 days

47
Q

txt for acetaminophen poisoning?

A

charcoal and N-acetylcysteine

48
Q

txt for alcohol poisoning?

A
  1. Inhibit alcohol dehydrogenase( Ethanol or Fomepizole)

2. Removal of alcohol & it’s metabolites: Hemodialysis

49
Q

salicylate (ASA) poisoning txt ?

A
  1. Activated charcoal
  2. Supplemental glucose
  3. Alkalinization of serum & urine
  4. Dialysis (hemodialysis)
50
Q

what do we give for TCA overdose? why?

A

give Magnesium! prevents torsades!

51
Q

what can TCA overdose cause? (4)

A
  1. Cardiac: QRS prolongation (can become torsades)
  2. Hypotension, Decreased CO
  3. CNS: Delerium, seizures, coma
  4. Anticholinergic tox effects
52
Q

TCA overdose txt (4)

A

ABCs
Activated charcoal
Gastric decontamination
NaHCO3 - most effective therapy!

53
Q

BB overdose txt

A 
ABCs
Activated charcoal
Temporary pacing/vasopressors prn
Glucagon
High dose insulin/glucose drip
**Atenolol is dialyzable**
54
Q

CCB overdose txt

A 
ACBs
Activated charcoal
?Gastric lavage
Ca gluconate
Glucagon
Insulin/glucose infusion
55
Q

CO poisoning txt?

A

ABCs
100% FiO2
Hyperbaric O2

56
Q

what is phencyclidine?

A

PCP- a sympathomimetic

57
Q

what type of drug is ecstasy?

A

MDMA- a sympathomimetic

58
Q

what type of drugs are pesticides?

A

nerve agents/organophosphates- cholinergics

clin med (88 decks)

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