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PHRM 865 > Final - Toxicocolgy > Flashcards

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

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2
Q

Anion Ga

what is the equation?

A

(Na + K) - Cl - HCO3

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3
Q

Anion gap is present when the value of the equation is ______

A

is above 14

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4
Q

Normal reference range of osmolarity

A

285 - 300

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5
Q

Osmolar Gap = ________ - ________

A

measured osmolarity - calculated osmolarity

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6
Q

How to calculate osmolarity?

A

(2 x Na) + (BUN/2.8) + (Glu/18) + (EtOH/4.6)

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7
Q

Osmolar gap is present when ____

A

greater than 10

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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
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9
Q

Activated Charcoal:

issues with it?

A

hard to administer (tastes AWFUL)

can not give when airway is unprotected (aspiration risk)

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10
Q

dose of activated charcoal?

A

1 - 2 GRAMS/kg (use actual body weight)

aka 50 - 100 grams in an adult

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11
Q

what drugs are examples of cathartics

A

magnesium citrate

sorbitol

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12
Q

complications from gastric lavage?

A

vomiting
aspiration
mechanical injury

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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
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14
Q

Whole bowel irrigation:

keep doing it until what?

A

go until there is CLEAR rectal effluent

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15
Q

dose for adults with whole bowel irrigation?

A

1000 - 2000 mL/HOUR!!!!!

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16
Q

Hemodialysis is good when what types of poisoning?

A

alcohols
lithium
salicylates
theophylline

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17
Q

Signs and symptoms of opioid toxicity

A 
N/V
Drowsiness
PINPOINT pupils
Hypotension
bradycardia
respiratory depression
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18
Q

drug to use when opioid overdose??

A

naloxone…

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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

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20
Q

APAP Toxicity:

what is a toxic dose?

A

7.5 - 15 grams

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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
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22
Q

APAP Toxicity:

protective conditions?

A

acute alcohol ingestion

children

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23
Q

APAP Toxicity:

APAP gets converted to ______ (the toxic metabolite) by CYP ______

A

NAPQI; CYP 2E1

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24
Q

APAP Toxicity:

NAPQI –> _________ = necrosis

A

APAP-cysteine groups

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25
Q

APAP Toxicity- Timeline:

Peak AST/ALTs wont happen until how long after ingestion?

A

72 - 96 hours

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26
Q

APAP Toxicity - Timeline
____ and ____ rise first;
then ____ and ____ will rise

A

AST/ALT first

then bilirubin and PT

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27
Q

2 treatment options with APAP Toxicity?

A

NAC (N-acetylcysteine)

Activated charcoal

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28
Q

Which treatment option for APAP Toxicity is recommended within the first 4 hours of ingestion?

A

activated charcoal (get it before it absorbs!)

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29
Q

Which treatment option for APAP toxicity needs an APAP concentration obtained at least 4 hours AFTER ingestion? and why?

A

NAC

Why = because look at a nomogram to see if NAC would help or not

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30
Q

what nomogram is used to see if NAC is needed

A

Rumack-Matthew Nomogram

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31
Q

MOA of NAC?

A

glutathione analogue that can serve as an intracellular glutathione surrogate

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32
Q

how is NAC available (formulation wise)

A

PO and IV

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33
Q

How long to use NAC as treatment?

A

if IV = 21 hours

if PO = 72 hours

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34
Q

NAC is most effective within the first _____ hours of ingestion

A

8 hours

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35
Q 
Salicylate Toxicity:
electrolyte disturbance(s)?
A

Hypokalemia

Hypo/hyper natremia

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36
Q

Salicylate Toxicity - Concentrations:
Mild toxicity: > ____ mg/dL
Severe toxicity: > ____ mg/dL

A

mild: > 30
severe: > 80

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37
Q

Signs/Sxs of Salicylate Toxicity?

A
  • 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)
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38
Q

Salicylate Toxicity - Concentrations:
For analgesic properties: ___ - ___ mg/dL
For anti-inflammatory properties: ___ - ___ mg/dL

A

analgesic: 10 - 15

anti-inflame: 15 - 20

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39
Q

Salicylate Toxicity:

will see an ____ anion gap = metabolic _____

A

an elevated anion gap

metabolic acidosis

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40
Q

Salicylate Toxicity:

Antidote option?

A

sodium bicarbonate

41
Q

MOA of Sodium bicarbonate with salicylate toxicity?

A

urine alkalinization

42
Q

Indications for sodium bicarbonate in Salicylate Toxicity?

A
  • Serum salicylate level > 30 mg/dL
  • Anion gap metabolic acidosis
  • altered mental status
43
Q

Sedatives Toxicity: Signs and Symptoms?

A

similar to opioids (but NO pinpoint pupils)

  • CNS depression
  • Respiratory depression
  • Hypotension
  • Bradycardia
44
Q

what is the drug that is competes with BZDs and the GABA binding site?

A

flumazenil

45
Q

Flumanezil: used when in sedative toxicity?

A

used almost never…..

can cause seizures…..and then benzos cant be given to fix the seizure because the drug was given

46
Q

TCA Toxicity – Signs and Symptoms?

A
  • altered mental status
  • hypotension
  • tachycardia
  • PROLONGED QRS
  • seizures
  • anticholinergic symptoms
47
Q

how to treat sedative toxicity?

A

just supportive care – avoid FLUMAZENIL

48
Q

TCA PK:

highly hydro- or lipo- philic

A

lipophilic

49
Q

TCA Antidote?

A

Sodium Bicarbonate

50
Q

MOA of Sodium Bicarbonate for TCAs?

A

increase of sodium gradient of poisoned sodium channels

51
Q

Monitor what when giving sodium bicarbonate?

A

Serum pH 7.45-7.55

Monitor QRS/ECG

52
Q

Antipsychotics:
1st gen: _____ antagonism
2nd gen: ________ antagonism

A

1st: D2 only
2nd: 5HT2A AND D2 antagonism

53
Q

Antipsychotics Toxicity: Signs and Symptoms?

A
  • hypotension
  • tachycardia
  • QT/QRS prolongation
  • EPS (extrapyramidal symptoms)
  • NMS (neuroleptic malignant syndrome)
  • Sedation
54
Q

what to give when extrapyramidal sxs present?

A

Benztropine

diphenhydramine

55
Q

NMS symptoms?

A

Hyperpyrexia (fever of like 108!!)
altered mental status
“lead pipe” muscular rigidity

56
Q

NMS:

how to treat?

A

stop offending agent (probably an atypical antipsychotic)
benzos
rapid external cooling
Dantrolene (muscle relaxant)

57
Q

symptoms seen in serotonin syndrome?

A

altered mental status
autonomic instability
neuromuscular abnormalities

58
Q

Serotonin syndrome: how to treat?

A

d/c agent
benzos
aggressive cooling
cyproheptadine

59
Q

NMS or Serotonin Syndrome:

has a higher fever

A

NMS

60
Q

NMS or Serotonin Syndrome:

will respond to cyproheptadine

A

serotonin syndrome

61
Q

NMS or Serotonin Syndrome:

responds to bromocriptine

A

NMS

62
Q

NMS or Serotonin Syndrome:

lasts > 24 hours

A

NMS

63
Q

NMS or Serotonin Syndrome:

has DIFFUSE lead pipe rigidity

A

NMS

64
Q

NMS or Serotonin Syndrome:

lower limbs are affected more than upper limbs

A

serotonin syndrome

65
Q

Digoxin Toxicity: Signs and Symptoms:

Non cardiac??

A 
N/V
abdominal pain
anorexia
confusion
VISION CHANGES!!! yellow halo
66
Q

Digoxin Toxicity: Signs and Symptoms:

Cardiac??

A

Bradycardia
2nd/3rd degree heart block
arrhythmias
hyperkalemia

67
Q 
how to treat digoxin toxicity:
stop \_\_\_\_\_\_
\_\_\_\_\_ management
obtain \_\_\_\_\_\_\_ concentrations
monitor \_\_\_\_\_\_ changes
give \_\_\_\_\_\_\_\_\_\_\_ (if within 2 hours of ingestion)
Consider administration of \_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_ is NOT effective
A 
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
Q

Digibind dosing done how?

A

0.5 mg of dig binds to one vial of digibind

69
Q

CCB or BB or both toxicity?

hypoglycemia

A

BB

70
Q

CCB or BB or both toxicity?

hypotension/bradycardia

A

both

71
Q

CCB or BB or both toxicity?

bronchospasms

A

BB

72
Q

CCB or BB or both toxicity?

arrhythmias/cadiogenic shock

A

bot

73
Q

CCB or BB or both toxicity?

hyperglycemia

A

CCB

74
Q

CCB or BB or both toxicity?

pulmonary edema

A

CCB

75
Q

CCB or BB or both toxicity?

metabolic acidosis

A

CCB

76
Q

potential options for combating CCB or BB toxicity?

A 
atropine
calcium
vasopressor therapy
glucagon
High dose insulin therapy
lipid emulsion therapy
77
Q

Calcium:

more effective for treating CCB toxicity or BB toxicity?

A

CCB

78
Q

Calcium MOA for treating CCB toxicity?

A

Calcium opens Calcium channels = leads to myocardial contractility

79
Q

what drugs are used for vasopressor therapy for BB toxicity?

A

epinephrine and norepinephrine (gotta use higher doses than normal to combat those beta receptors)

80
Q

how does glucagon work for BB toxicity?

A

bypasses beta receptor and acts directly on Gs to stimulate conversion of ATP to cAMP

81
Q

dosing for glucagon in BB toxicity?

A

minimum of 3 mg!!! 1 mg wont do the trick.

82
Q

MOA of high dose insulin therapy for CCB and BB toxicity?

A

increased inotropy and increase intracellular glucose transport

83
Q

dosing of insulin for CCB and BB toxicity?

A

like 1 unit/kg/hr IV

vs like normal insulin is 0.1 unit/kg/hr for DKA treatment

84
Q

MOA of lipid emulsion therapy?

A

limits bioavailability of lipophilic medication by creating a lipid sink

85
Q

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

A

atropine

86
Q

Calcium Chloride vs gluconate:

______ has 3x more elemental Ca2+ in it but also has higher extravasation

A

Chloride

87
Q

Toxicology Tidbits Slide: (out of the 6 proposed methods for CCB/BB toxicity)
______ therapy should be pre-medicated with anti-nausea meds

A

glucagon

88
Q

Iron Toxicity Management:

Activated Charcoal: yay or nay?

A

Nay

89
Q

Iron Toxicity:

Seen right away or in phases?

A

phases

day 2 - 3 see hepatoxicity

90
Q

Iron Toxicity Management:

Whole bowel irrigation: yay or nay?

A

yay!

91
Q

Iron Toxicity Management:

what is the iron antidote drug?

A

Deferoxamine (Desferal)

92
Q

how does Deferoxamine work?

A

chelates iron and enhances renal elimination

93
Q

which toxic alcohol is found in:

antifreeze, brake fluid/industry solvents

A

ethylene glycol

94
Q

which toxic alcohol is found in:

rubbing alcohol, paint remover, cements, cleaners

A

isoproypyl alcohol

95
Q

which toxic alcohol is found in:

windshield washer fluid, paint remover, copier fluid, some antifreeze/engine fuels

A

methanol

96
Q

which toxic alcohol toxicity has an osmolar gap but NO anion gap

A

isopropyl alcohol

97
Q

Ethylene glycol gets broken down to _____ acid which is the toxic metabolite

A

oxalic

98
Q

For ethylene glycol toxicity:

give what to prevent it from getting metabolized to oxalic acid?

A

vitamins!! Thiamine; Mg2+; Pyridoxine

PHRM 865 (59 decks)

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