Final - Toxicocolgy Flashcards
1
Q
Initial things to do when a poisoning happens:
what things are used for stabilization?
A
ABC management (airway, breathing, circulation)
Vital signs
IV access
Oxygenation
2
Q
Anion Ga
what is the equation?
A
(Na + K) - Cl - HCO3
3
Q
Anion gap is present when the value of the equation is ______
A
is above 14
4
Q
Normal reference range of osmolarity
A
285 - 300
5
Q
Osmolar Gap = ________ - ________
A
measured osmolarity - calculated osmolarity
6
Q
How to calculate osmolarity?
A
(2 x Na) + (BUN/2.8) + (Glu/18) + (EtOH/4.6)
7
Q
Osmolar gap is present when ____
A
greater than 10
8
Q
generic decontamination strategies when pt presents with a poisoning?
A
- Activated charcoal
- cathartics (accelerates defecation)
- gastric lavage (stomach pump)
- whole bowel irrigation (hella polyethylene glycol)
- hemodialysis
9
Q
Activated Charcoal:
issues with it?
A
hard to administer (tastes AWFUL)
can not give when airway is unprotected (aspiration risk)
10
Q
dose of activated charcoal?
A
1 - 2 GRAMS/kg (use actual body weight)
aka 50 - 100 grams in an adult
11
Q
what drugs are examples of cathartics
A
magnesium citrate
sorbitol
12
Q
complications from gastric lavage?
A
vomiting
aspiration
mechanical injury
13
Q
whole bowel irrigation is good when what types of poisonings?
A
- sustained release products
- body packers/stuffers aka bags of cocaine were swallowed
- iron
- lithium
14
Q
Whole bowel irrigation:
keep doing it until what?
A
go until there is CLEAR rectal effluent
15
Q
dose for adults with whole bowel irrigation?
A
1000 - 2000 mL/HOUR!!!!!
16
Q
Hemodialysis is good when what types of poisoning?
A
alcohols
lithium
salicylates
theophylline
17
Q
Signs and symptoms of opioid toxicity
A
N/V Drowsiness PINPOINT pupils Hypotension bradycardia respiratory depression
18
Q
drug to use when opioid overdose??
A
naloxone…
19
Q
Naloxone:
use lower doses when _____
use higher doses when ____
use continuous infusions when ______
A
lower: when chronic opioid dependence to avoid withdrawal
higher: when if illicit drug use suspected (heroin, fentanyl and derivative)
continuous infusion: when longer acting opioid
20
Q
APAP Toxicity:
what is a toxic dose?
A
7.5 - 15 grams
21
Q
APAP Toxicity:
what are things that make someone a high risk candidate
A
- malnutrition/chronic illness
- concomitant CYP2E1 inducers (isoniazid)
- chronic alcohol ingestion
22
Q
APAP Toxicity:
protective conditions?
A
acute alcohol ingestion
children
23
Q
APAP Toxicity:
APAP gets converted to ______ (the toxic metabolite) by CYP ______
A
NAPQI; CYP 2E1
24
Q
APAP Toxicity:
NAPQI –> _________ = necrosis
A
APAP-cysteine groups
25
APAP Toxicity- Timeline:
| Peak AST/ALTs wont happen until how long after ingestion?
72 - 96 hours
26
APAP Toxicity - Timeline
____ and ____ rise first;
then ____ and ____ will rise
AST/ALT first
then bilirubin and PT
27
2 treatment options with APAP Toxicity?
NAC (N-acetylcysteine)
| Activated charcoal
28
Which treatment option for APAP Toxicity is recommended within the first 4 hours of ingestion?
activated charcoal (get it before it absorbs!)
29
Which treatment option for APAP toxicity needs an APAP concentration obtained at least 4 hours AFTER ingestion? and why?
NAC
| Why = because look at a nomogram to see if NAC would help or not
30
what nomogram is used to see if NAC is needed
Rumack-Matthew Nomogram
31
MOA of NAC?
glutathione analogue that can serve as an intracellular glutathione surrogate
32
how is NAC available (formulation wise)
PO and IV
33
How long to use NAC as treatment?
if IV = 21 hours
| if PO = 72 hours
34
NAC is most effective within the first _____ hours of ingestion
8 hours
35
```
Salicylate Toxicity:
electrolyte disturbance(s)?
```
Hypokalemia
| Hypo/hyper natremia
36
Salicylate Toxicity - Concentrations:
Mild toxicity: > ____ mg/dL
Severe toxicity: > ____ mg/dL
mild: > 30
severe: > 80
37
Signs/Sxs of Salicylate Toxicity?
- N/V
- tinnitus and vertigo (seen at mild toxicity)
- decreased GI motility
- altered mental status (seen at severe toxicity)
- seizures (seen at severe toxicity)
- lethargy coma (seen at severe toxicity)
38
Salicylate Toxicity - Concentrations:
For analgesic properties: ___ - ___ mg/dL
For anti-inflammatory properties: ___ - ___ mg/dL
analgesic: 10 - 15
| anti-inflame: 15 - 20
39
Salicylate Toxicity:
| will see an ____ anion gap = metabolic _____
an elevated anion gap
metabolic acidosis
40
Salicylate Toxicity:
| Antidote option?
sodium bicarbonate
41
MOA of Sodium bicarbonate with salicylate toxicity?
urine alkalinization
42
Indications for sodium bicarbonate in Salicylate Toxicity?
- Serum salicylate level > 30 mg/dL
- Anion gap metabolic acidosis
- altered mental status
43
Sedatives Toxicity: Signs and Symptoms?
similar to opioids (but NO pinpoint pupils)
- CNS depression
- Respiratory depression
- Hypotension
- Bradycardia
44
what is the drug that is competes with BZDs and the GABA binding site?
flumazenil
45
Flumanezil: used when in sedative toxicity?
used almost never.....
| can cause seizures.....and then benzos cant be given to fix the seizure because the drug was given
46
TCA Toxicity -- Signs and Symptoms?
- altered mental status
- hypotension
- tachycardia
- PROLONGED QRS
- seizures
- anticholinergic symptoms
47
how to treat sedative toxicity?
just supportive care -- avoid FLUMAZENIL
48
TCA PK:
| highly hydro- or lipo- philic
lipophilic
49
TCA Antidote?
Sodium Bicarbonate
50
MOA of Sodium Bicarbonate for TCAs?
increase of sodium gradient of poisoned sodium channels
51
Monitor what when giving sodium bicarbonate?
Serum pH 7.45-7.55
| Monitor QRS/ECG
52
Antipsychotics:
1st gen: _____ antagonism
2nd gen: ________ antagonism
1st: D2 only
2nd: 5HT2A AND D2 antagonism
53
Antipsychotics Toxicity: Signs and Symptoms?
- hypotension
- tachycardia
- QT/QRS prolongation
- EPS (extrapyramidal symptoms)
- NMS (neuroleptic malignant syndrome)
- Sedation
54
what to give when extrapyramidal sxs present?
Benztropine
| diphenhydramine
55
NMS symptoms?
Hyperpyrexia (fever of like 108!!)
altered mental status
"lead pipe" muscular rigidity
56
NMS:
| how to treat?
stop offending agent (probably an atypical antipsychotic)
benzos
rapid external cooling
Dantrolene (muscle relaxant)
57
symptoms seen in serotonin syndrome?
altered mental status
autonomic instability
neuromuscular abnormalities
58
Serotonin syndrome: how to treat?
d/c agent
benzos
aggressive cooling
cyproheptadine
59
NMS or Serotonin Syndrome:
| has a higher fever
NMS
60
NMS or Serotonin Syndrome:
| will respond to cyproheptadine
serotonin syndrome
61
NMS or Serotonin Syndrome:
| responds to bromocriptine
NMS
62
NMS or Serotonin Syndrome:
| lasts > 24 hours
NMS
63
NMS or Serotonin Syndrome:
| has DIFFUSE lead pipe rigidity
NMS
64
NMS or Serotonin Syndrome:
| lower limbs are affected more than upper limbs
serotonin syndrome
65
Digoxin Toxicity: Signs and Symptoms:
| Non cardiac??
```
N/V
abdominal pain
anorexia
confusion
VISION CHANGES!!! yellow halo
```
66
Digoxin Toxicity: Signs and Symptoms:
| Cardiac??
Bradycardia
2nd/3rd degree heart block
arrhythmias
hyperkalemia
67
```
how to treat digoxin toxicity:
stop ______
_____ management
obtain _______ concentrations
monitor ______ changes
give ___________ (if within 2 hours of ingestion)
Consider administration of ________
__________ is NOT effective
```
```
stop dig
ABC management
obtain dig serum concentrations
monitor ECG changes
give ACTIVATED CHARCOAL (if within 2 hours of ingestion)
Consider administration of digibind
Hemodialysis is NOT effective
```
68
Digibind dosing done how?
0.5 mg of dig binds to one vial of digibind
69
CCB or BB or both toxicity?
| hypoglycemia
BB
70
CCB or BB or both toxicity?
| hypotension/bradycardia
both
71
CCB or BB or both toxicity?
| bronchospasms
BB
72
CCB or BB or both toxicity?
| arrhythmias/cadiogenic shock
bot
73
CCB or BB or both toxicity?
| hyperglycemia
CCB
74
CCB or BB or both toxicity?
| pulmonary edema
CCB
75
CCB or BB or both toxicity?
| metabolic acidosis
CCB
76
potential options for combating CCB or BB toxicity?
```
atropine
calcium
vasopressor therapy
glucagon
High dose insulin therapy
lipid emulsion therapy
```
77
Calcium:
| more effective for treating CCB toxicity or BB toxicity?
CCB
78
Calcium MOA for treating CCB toxicity?
Calcium opens Calcium channels = leads to myocardial contractility
79
what drugs are used for vasopressor therapy for BB toxicity?
epinephrine and norepinephrine (gotta use higher doses than normal to combat those beta receptors)
80
how does glucagon work for BB toxicity?
bypasses beta receptor and acts directly on Gs to stimulate conversion of ATP to cAMP
81
dosing for glucagon in BB toxicity?
minimum of 3 mg!!! 1 mg wont do the trick.
82
MOA of high dose insulin therapy for CCB and BB toxicity?
increased inotropy and increase intracellular glucose transport
83
dosing of insulin for CCB and BB toxicity?
like 1 unit/kg/hr IV
| vs like normal insulin is 0.1 unit/kg/hr for DKA treatment
84
MOA of lipid emulsion therapy?
limits bioavailability of lipophilic medication by creating a lipid sink
85
Toxicology Tidbits Slide: (out of the 6 proposed methods for CCB/BB toxicity)
______ is not likely to be effective in either CCB or BB overdoses
atropine
86
Calcium Chloride vs gluconate:
| ______ has 3x more elemental Ca2+ in it but also has higher extravasation
Chloride
87
Toxicology Tidbits Slide: (out of the 6 proposed methods for CCB/BB toxicity)
______ therapy should be pre-medicated with anti-nausea meds
glucagon
88
Iron Toxicity Management:
| Activated Charcoal: yay or nay?
Nay
89
Iron Toxicity:
| Seen right away or in phases?
phases
| day 2 - 3 see hepatoxicity
90
Iron Toxicity Management:
| Whole bowel irrigation: yay or nay?
yay!
91
Iron Toxicity Management:
| what is the iron antidote drug?
Deferoxamine (Desferal)
92
how does Deferoxamine work?
chelates iron and enhances renal elimination
93
which toxic alcohol is found in:
| antifreeze, brake fluid/industry solvents
ethylene glycol
94
which toxic alcohol is found in:
| rubbing alcohol, paint remover, cements, cleaners
isoproypyl alcohol
95
which toxic alcohol is found in:
| windshield washer fluid, paint remover, copier fluid, some antifreeze/engine fuels
methanol
96
which toxic alcohol toxicity has an osmolar gap but NO anion gap
isopropyl alcohol
97
Ethylene glycol gets broken down to _____ acid which is the toxic metabolite
oxalic
98
For ethylene glycol toxicity:
| give what to prevent it from getting metabolized to oxalic acid?
vitamins!! Thiamine; Mg2+; Pyridoxine
