General Flashcards
What are odors that can indicate an ingested subastance?
1Bitter Almonds 2Carrots 3Fishy 4Fruity 5Garlic 6Glue 7Pears 8Rotten eggs 9Show polish 10Wintergreen
1HCN 2Water hemlock (cicutoxin) 3Zn or aluminum phosphide 4EtOH, acetone, isopropyl alcohol, chlorinated hydrocarbons (chloroform) 5As, DMSO, organophosphate, yellow phosphorous, selenium, tellurium 6Tolune, solvents 7Chloral hydrate, paraldehyde 8Disulfiram, HS, NAC, DMSA 9Nitrobenzene 10 Methyl salicylate
Describe the cholinergic toxidrome
- Wet compared to the dry anticholinergic
- Muscarinic: DUMBELS
o Diarrhea, Urination, Miosis, Bronchospsasm/Bradycardia/Bronchorrhea, Emesis, Lacrimation, Salivation/Secretion/Sweating - Nicotinic: Days of the week
o Mydriasis, Tachycardia, Weakness, Hypertension, Hyperglycemia, Fasciculations - Source:
Organophosphate and carbamate insecticides, physostigmine, edrophonium, some mushrooms, anticholinesterase agents (VX, sarin, soman, tabun)
Describe the cholinergic toxidrome
Mad as a hatter Dry as a bone hot as a hare blind as a bat red as a beet
Describe the sympathomimetic toxidrome
Delusions, paranoia, tachycardia, HTN, mydriasis, diaphoreticm hyperreflexic
Common causes: cocain, MDMA, caffeine, theophylline
List the drugs / envenomations that cause the following skin conditions:
Cyanosis
Yellow skin
Flushing
Gray skin
Escar
Bulae
Red skin
Transverse lines
Cyanosis
- Deoxyhemoglobins
- Methemoglobin
Yellow skin -
Carontinemia
- Cigarettes
- Dinotrophenol
- Picric acid
Flushing
- Anticholinergics
- Scromboid
- EtOH (ADH deficiency)
- Disulfiram
- Niacin
- Nitrates
Gray skin
- Metalic silver
- Gold
Escar
- Radiation exposure
- Anthrax
- Brown recluse spider venom
Bulae
- Barbiturates
- Chemotherapy drugs
Red skin
- Vancomycin
- Carbon monoxide
- Boric acid
Transverse lines
- Arsnic
- Chemotherapy
- TraumaList drugs that can cause hyperthermia (8)
Hyperthermia: - anticholinergics - Herbicides - MH - MAOIs - NMS - Salicylates - PCP - WD – opiods, EtOH - Serotonin syndrome - Sumpathomimetics Thyroid hormone
List drugs that can cause hypothermia
Hypothermia:
- Alpha 2 agonists
- CO
- EtOH
- GHB
- Hypoglycemics
- Opiods
- Sedative hypnotics
- thiamine deficiency
List 8 drugs that can cause hypertension:
- alpha-1 agonists
- alpha-2 antagonists
- ergot alkaloids
- Lead (chronic)
- MAOI (early OD, food interaction)
- Nicoteine (early)
- Phenylcyclidine (PCP)
- Sympathomimetics
Yohimbine
List 8 drugs that can cause hypotension:
- alpha-1 antagonists
- alpha-2 agonists
- beta antagonists
- Cyclic antidepressants
- ACE-I, ARBs
- Antidysrhythmics
- CCBs
- HCN
- EtOH + other alcohols
- Fe
- Methylxanthines
- Nitrates and nitrites
- Nitroprusside
- Opiods
- Phenothiazines
- Phosphodiesterase inhibitors
- Sedative hypnotics
List 8 drugs that can cause tachycardia
- Anticholinergics
- Antipsychotics
- SSRI / SNRI
- TCAs
- Disulfiram + EtOH
- Fe
- Methylxanthines
- PCP
- Sympathomimetic
- Thyroid hormone
- Yohimbine
List 8 drugs that cause bradycardia
- alpha-2 agonists
- BB’s
- Baclofen
- Cholinergics
- CCB
- Dig
- Ergot alkaloids
- GHB
- Opoids
Organic phosphorouns compounds
List 8 drugs that can cause tachypnea
- HCN
- Ethylene glycol
- Methanol
- H2S
- Methemoglobin producers
- Methylxanthines
- Nicoteine (early)
- Pulmonary irritatnts
- Salicylates
- Sympathomimetics
List 8 drugs that cause bradypnea
- alpha-2 agonists
- Botulism
- EtOH + other alcohols
- GHB
- NM blockers
- Opiods
- Organophosphates
- Sedative hypnotics
List 7 agents that cause hypoglycemia
- PO hypoglycemics o Meglitinides – Repaglinide o Sulonylureas – Glyburide - Insulin - EtOH - Salicylates - Quinine - Haldol - BBs
What are examples of sulfonylureas?
- Gliclazide
- Glyburide
- Glimepiride (found in combo with metformin or pioglitazone)
- Glipizide
List 8 agents that are on the “one pill can kill” list (Table 31-4 Goldfranks)
- Sulfonylureas
- Theophylline
- Quinine, chloroquine
- Phenothiazines (chlorpromazine)
- Methanol / ethylene glycol
- Benzocaine
- Lomotil (Diphenoxylate + atropine)
- Methylsalicylate
- CCB SR
- BB SR
- Clonidine
- Camphor
- TCAs
- MAOIs
- Opiods
Methadone
List 5 drugs that cause nystagmus:
- Lithium
- Ketamine
- PCP
- Dextromethorphan (DXM)
- Lamotragine
- Phenuytoin
Carbamazepine
List 3 drugs that cause mydriasis (dilated):
- Anticholinergocs
- Sympathomimetics
- LSD
Opiate or EtOH WD
List 5 drugs that cause miosis (pinpoint)
- Narcotics
- Anticholinesterases
- Organophosphates
- PCP
- Mushrooms
- GHB
- Neostigmine
- Pilocarpine
- Clonidine
- Phenothiazines
List 8 causes for drug induced seizures:
- Cocaine + other stimulants
- TCA
- Venlafaxine
- Buproprion
- Citalopram
- Duloxetine
- Local anasthetics
- ASA
- INH
- Insulin
- Anticholinergics
- Organophosphates
- Antihistamines
- EtOH WD
- GHB WD
- BZD WD
- Lead
- Lithium (although not common)
- PCP
- Camphor (vicks vaporub, moth balls))
- Methylxanthines (theophylline)
- Hypoglycemics
- Nicoteine OD
List 9 drugs that cause a WCT:
- Na channel blockers
- TCA
- Cocaine
- Digoxin
- Quinine
- Chloroquine / hydroxychloroquine
- Phenothiazines (chlorpromazine)F
- Antihistamine
- Amphetamine
Provide your differential for conditions and agents that prolong the QT:
Medications: the Anti’s: - Antipsychotics (Haldol, respiridone, Lithium, chlorpromazine) - Antidepressants (TCA’s, SSRI’s, MAOIs) - Antihistamines (gravol) - Antiemetics (maxeran, ondansetron) - Anticonvulsants (Dilantin, tegretol) - Antibiotics (fluroquinolones, macrolides, septra) - Antifungals (ketoconazole, fluconazole) - Anti-parasitic (quinidine, quinine, hydroxychloroquine) - Anti-dysrrythmics: (procainamide, propafenone, sotalol, amiodarone) Electrolytes: - Hypomagnesia - Hypokalemia - Hypocalcemia Organophosphates Cardiac ischemia Hypothyroidism Hypothermia Congenital Elevated ICP
What is the DDx of drugs that prolong the QRS?
TCAs
- Antidysrythmics: 1a, 1c
- Antihistamines
- Amantadine
- Cocaine
- Propanolol
- Phenothiazines
- Diphenhydramine
- Carbamazepine
- Bupriorion
List 6 radio-opaque toxins:
- CHIPES
- C – Chloral hydrate, Calcium carbonate
- H – Heavy metals (lead, arsenic)
- I – Iron
- P – Phenothiazines, Packets
- E – Enteric coated tablets
- S – Salycilates, salt, stuffers
List 9 ways to decontaminate a patient:
- Removal of contaminated clothing
- Washing / irrigation contaminated skin / eyes
- WBI
- Gastric lavage
- AC
- Vomiting (ie syrup of ipecac, not recommended)
- Cathartics
- Endoscopic removal
- Surgical removal
What are contraindications to gastric lavage?
- The patient does not meet criteria for gastric emptying
- Will lose airway (Can do after airway secured)
- Ingestion of alkaline caustic
- Ingestion of FB (id drug packet)
- Ingestion of drug with high potential for aspiration (ie hydrocardbon) in the unintubated patient
- Risk of GIB or GI perforation because of underlying pathology, surgery, or medical condition that could be further conmprimised
- Ingestion of drug in form known to be too big to fit through lavage lumen (many modified release preparations)
What is the dose of AC in adults and pediatrics?
- Adults: AC-to-drug ratio of 10:1, or 50-100g of AC à will absorb 5-10g of drug. Can also use 1g/kg
- Peds: 0.5-2g/kg
What are 6 contraindications to AC
- AC does not absorb the drug
- Airway is compromised, patient not intubated
- Caustic ingestion - GI perforation likely
- AC may increase the risk of aspiration (like with hydrocarbons)
- GI obstruction
- Endoscopy will ne needed (ie caustics)
- Surgical removal will be needed
What substances are not bound by AC?
(PHAILS)
- P – Pesticiedes, Potassium
- H – Hydrocarbons
- A – Acids, Alkali, Alcohols
- I – Iron, insecticides
- L – Lithium
- S – Solvents
How does MDAC enhance elimination?
- By reducing drug absorption
- By reducing enterohepatic recirculation
What 5 ingestions should MDAC be considered?
- Recommended by AACT and EAPCCT: o Carbamazepine o Dapsone o Phenobarbital o Quinine o Theophylline - Goldfrank’s others to consider: o Amitriptyline o Digoxin o Nadolol o Phenytoin o Piroxicam o Sotalol
How is PEG (go-litely) in WBI dosed?
- Peds: 0.5L/h or 25cc/kg/hr
- Adult: 2L/hr x 4-6 hours or until rectal effluent clear
List 9 ways to increase elimination of a drug once absorbed into the body:
- Diuresis
- Hemodialysis
- Peritoneal dialysis
- MDAC
- Drug specific antibody fragments (ie digibind)
- Chelation
- Exchange transfusion
- Plasmapheresis
- NG suction
- Ion trapping – urinary pH manipulation
- Hemofiltration
- Charcoal hemoperfusion
What are characteristics of a drug that make it amenable to dialysis?
- Small Vd
- Water soluble (single compartment kinetics)
- Not protein bound
- Small molecular weight (<500 daltons)
List 6 agents that are dialyzable?
“SVELT BM”
- Salicylates
- Valroic acid
- Ethylene glycol
- Lithium
- Theophjylline / Caffeine
- BBs: “NASA” atenolol/acebutolol, nadolol, sotalol
- Methanol
List 5 agents amenable to urine alkalization:
- ASA
- Phenobarbital
- Isoniazid
- TCA
- Quinolones
Methotrexate
Define pharmacokinetics and pharmacodynamics:
- Pharmacokinetics: How drugs are absorbed, distributed, metabolized, and excreted – what the body does to the drug
- Pharmacodynamics: What effect the drug has on the body.
What is the volume of distribution?
- Vd = volume of drug in the body/volume of drug in the blood
- Higher Vd = More distributed into tissues = Less amenable to dialysis
List 6 drugs that may respond to narcan:
- Valproic acid
- Clonidine
- EtOH
- Opiods
- Tramadol
? Captopril
What mushrooms cause the following:
- liver failure
- renal failure
- seizures
- cholinergic Sx
- Disulfram
- amanita phalloides
- Amanita smithania (allenic), orellanine
- Gyrometrum, Amanita muscaria
- C. dealbata
- Corpine (inky caps)
What are the 4 major causes of toxicity with herbal medications
- misidentification and substitution
- contamination with non-herbal toxic material
- OD
- drug-herbal interaction
List signs and symptoms consistent with severe barbiturate toxicity.
- CNS depression (stupor – coma)
- Respiratory arrest
- Normal or small, but reactive pupils
- Diminished corneal and gag reflexes
Flaccid muscle tone - Absent DTR
- +/- motor posturing
- Hypotension
- Noncardiogenic pulmonary edema
- Hypothermia
What is the management of barbiturate overdose?
- Supportive
- ABCS
o Careful, but adequate fluid resuscitation
o Vasopressors as needed - Rewarming (active if <30C)
- Charcoal (multidose)
- Dialysis à if extremely large ingestions that would require prolonged intubation
What is the mechanism of action of benzodiazepines?
- Enhances inhibitory action of GABA (Increasing influx of Cl- and hyperpolarizing the cell)
What is the main difference in action at the GABA receptor Cl channel between benzodiazepine and barbiturates?
- Benzodiazepines o Cause the chloride channel to open more often o Requires the presence of GABA - Barbiturates o Hold the channel open longer o Does not require GABA
What cardiotoxic effect does diphenhydramine share with TCAs?
- Quinine-like affect on sodium channels prolonging QRS interval (NaHCO3 can be used)
