Lecture 15: Poisonings Flashcards
The first thing you do with a patient that rolls into the ED with poison on her is..
Gross decontamination prior to assessment
do not let it touch you!
T/F: Most toxidromes will respond to IVF.
False.
What do you give first, thiamine or dextrose?
THIAMINE
GLucose first => worse wernicke’s encephalopathy
A new onset seizure that needs pharm tx should first be managed with IV (), but if it persists, you should () the dose. If it really persists, you should give IV () and intubate.
- Start with IV ativan
- Double ativan
- Phenobarbital and intubate
The treatment for isoniazid-induced seizures is…
The I in RIPE therapy for TB tx :)
Vit B6 pyridoxine
() is highly ineffective for tx of seizures due to poisonings.
Phenytoin
Anticholinergics will cause your pupils to (), whereas cholinergics cause them to ()
- Anticholinergic = mydriasis/dilation
- Cholinergic = miosis
Cholinergic = Constrict eyes or Anti = your eyes are going AHHHHHH
Also anticholinergics = dry like MY DRY iasis
You suspect your poisoned patient was a drug mule for cocaine. You should order what imaging to confirm your suspicion?
Abd XRAY
T/F: A tox screen is indicated in patients with accidental ingestion and are asymptomatic with a consistent history.
FALSEEE
Ethlyene glycol poisoning/antifreeze poisoning can present with what kind of crystals in the urine?
Calcium oxalate
Cause it makes OXAlic acid!
The preferred method of decontaminating gastric contents is () if the ingestion was less than () hours prior to arrival. It is CONTRAINDICATED if the patient cannot maintain their own ()
- Activated charcoal
- Ingestion must be within 1 hour prior to arrival
- Cannot use if airway cannot be protected
Also if the toxin doesn’t have an antidote alrdy. Note the 2 exceptions!
T/F: Activated charcoal can bind tylenol, alcohol, metals, and corrosives.
FALSE
Cannot bind alcohol, metals, or corrosives
Gastric lavage is best delivered via (NG/OG) tube.
OG tube
Whole bowel irrigation is indicated in:
- Ingestion of chemicals that () with charcoal
- Ingestion of () packets
- Poor binding chemicals with charcoal
- Drug-filled packets
T/F: Gastric irrigation does not require bowel sounds or normal peristalsis.
False.
Multi-dose activated charcoal is using at least () doses of oral activated charcoal.
At least 2 doses
Urinary alkalinization is primarily indicated in () poisonings
Moderate-severe salicylate poisonings
You must monitor (electrolyte) levels because hypo() will reduce urine alkalinity in salicylate poisoning tx.
Potassium levels, because HypoK will cause more H+ secretion instead
Goal: 4-4.5
Nephrooooo
Hemodialysis can remove highly () bound drugs and highly () soluble drugs.
Hemoperfusion can remove () soluble low molecular wt substances.
- Hemodialysis = protein bound and lipid solubles
- Hemoperfusion = water-soluble low molecular weight substances
Very invasive, very expensive!
In an inhaled poisoning patient, should you administer oxygen?
Yes silly
You can irrigate eyes with either () or ()
Water or NS
T/F: You should discard contaminated clothes.
Truee
Throw it out
What is the poison control hotline???????
1-800-222-1222
There are 3 Questions that must be addressed to determine if an exposure was NON-toxic:
- Was the exposure () and is there a clearly identified single substance?
- () of the agent was ingested?
- Can the () confirm the substance is nontoxic at that dose?
- Unintentional
- How much was ingested
- Can the CDC confirm?
Overall, the mainstay of treatment for any poisoning is…
Treat the patient, not the poison!
In a poisoned pt who is HTN and agitated, the drug of choice is…
BZDs
Bicarb can be useful for ()-QRS tachyarrhythmias
Wide-QRS
Naloxone can be administered 3 ways
- IV
- IM
- IN
The supportive care tx for cardiac arrhythmias is just correction of (), (), and administration of an antidote
- Correct hypoxia
- Correct any acid-base abnormalities
You should consider aggressive cooling in a poisoned patient once their temperature reaches…
39C or 102.2F
Re-warming is indicated once core temperature reaches…
< 32C or 90F
AG is calculated from:
Na - (Cl + HCO3)
Normal AG is 10-15
AG Metabolic acidosis causes is memorized by the mnemonic CAT MUDPILES.
In AG Metabolic acidosis, the first management step involves addressing any lack of () first.
Any lack of respiratory compromise is the first thing to check!!!!!
You’re acidotic! You better be tryna blow off some CO2
The presentation of narcotic/opioid toxidrome is memorized with the mnemonic CPR-3H
- Coma
- Pinpoint Pupils
- Respiratory Depression
- HypoTN
- Hypothermia
- Hyporeflexia
MATHS is the mnemonic for sympathomimetic
- Mydriasis/muscle cell death
- Agitation/Arrhythmia/Angina
- Tachycardia
- HTN/hyperthermia/Hyperactive bowel sounds
- Seizure/sweating
Everything is just firing off
The drug of choice for sympathomimetics toxicity is (). () is CONTRAINDICATED.
- BZDs for sympathomimetic toxicity.
- DO NOT USE BBs
The two drugs that cause CHOLINERGIC toxicity are:
- Organophosphate insectides
- Carbamate insecticides
AKA insecticides
The presentation of Cholinergic toxicity can be summed up in 3 words. () all over.
Crying all over
There are two drugs given for cholinergic toxicity.
- Atropine (Blocks muscaric receptors)
- Pralidoxime (reactivates acetylcholinesterase)
What very common medication used for motion sickness is also an anticholinergic like atropine :)
Scopolamine!
- Dry as a bone
- Mad as a hatter
- Full as a tick
- Blind as a bat
- Red as a beet
ANTIcholinergic toxicity
You can differ anticholinergic toxicity from sympathomimetic toxicity via (skin) and (bowel sounds)
- Dry skin
- Decreased bowel sounds
This is anticholinergic
The antidote for anticholinergic poisoning is…
Physostigmine
Cholinesterase inhibitor to increase Ach concentration
Used once conventional fails.
Anticholinergic poisoning slows GI so activated charcoal 1 hr window doesn’t apply
You can discharge someone home with anticholinergic toxicity after they have been asymptomatic for () hours
6 hours
() and () are the MC drug classes + non-BZDs that can cause sedation/hypnosis
- BZDs
- Barbiturates
For barbiturate poisoning that does NOT respond to supportive care, you should use enhanced excretion methods, such as () or ()
- Repeated charcoal
- Extracorporal removal (hemodialysis/perfusion)
BZD ODs can be confirmed by the presence of (), and the reversal agent is (), but it can precipitate seizures!!
- Respiratory depression
- Flumazenil
Same as for anticholinergic toxicity, you can discharge after () hours of no symptoms for sedative/hypnotic OD.
6 hours later
Some of the biggest drugs that can cause serotonin syndrome are:
- () inhibitors
- () reuptake inhibitors
- () in cough syrup
- () antidepressants
- L-(amino acid)
- MAO inhibitors
- SSRIs
- DXM
- TCAs
- L-tryptophan
The mnemonic for serotonin syndrome is HATS or SHAT which stands for
- Hyperthermia, HTN
- AMS, agitation
- Tremor, tone (rhabdo), Tachycardia/pnea
- Seizures
Initially, you should treat serotonin syndrome with (), but if that + supportive care fails, you should use a serotonin receptor antagonist called ()
- BZDs for agitation, tremors, and seizures
- Cyproheptadine is a serotonin receptor antagonist
T/F: All patients with serotonin syndrome get admitted.
TRUE
A common ingredient found in cough syrup can be used as a hallucinogenic and it is ()
DXM
Dextromethorphan
Other hallucinogenics are like LSD, PCP, psilocybin/shrooms, ecstasy, ketamine
For the agitation, hyperthermia, seizures, tachycardia and HTN in hallucinogenic OD, you should use ()
BZDs
In refractory hallucinogenic OD, once BZDs fail, you should consider () or () for refractory HTN. Otherwise, you should consider inducing a ()
- Nitroprusside or phentolamine for refractory HTN in hallucinogenic OD.
- Induce a medical coma if refractory.
Summary of all the toxidromes
BZD OD doesn’t affect pupils like an opioid OD!!!!
Brendans mnemonic is CHAOSSS
About 1/4 of the 450 deaths due to tylenol/APAP toxicity are unintentional, because in children, () occurs
Supratherapeutic dosing
AKA too much tylenol by accident :(
There are 4 demographics that are at an increased risk for APAP toxicity:
- Chronic () use
- AIDS
- () use
- anti-() therapy users
- Chronic alcohol use
- AIDS
- Anticonvulsant use
- anti-TB therapy user
In a patient 6 years or Older, > 10g of tylenol or 200mg/kg as a single ingestion in a () time period is a toxic exposure. BUT IF you are younger than 6, the time period changes to over ().
- Older is 24 hours
- Younger is 8 hours
Tylenol toxicity presents with 4 stages of toxicity.
- Stage 1 is characterized by: (symptoms) and (lab change)
- Stage 2 is characterized by improvement, but (lab changes)
- Stage 3 is characterized by ()itis and recurrent GI symptoms.
- Stage 4 is characterized by either () or ()
- Stage 1 = N/V + hypoK
- Stage 2 = ELEVATED LFTs
- Stage 3 = Pancreatitis + coagulopathy
- Stage 4 = improvement or multi-organ failure/death.
Every day is about 1 stage.
T/F: Even in an asymptomatic APAP OD patient, you should get serum APAP levels.
True
Can take 30-120 minutes to reach peak concentration!
A rumack-matthew monogram is used in () toxicity. It is for clinical outcome determination and can only be used after acute ingestion between () to () hours
- APAP toxicity
- 4-24 hours
Just know tx above the line!
The main drug of choice to counter APAP toxicity is.., and its MOA is to prevent metabolites from binding to () cells and diminishing hepatic ()
usuall Within 8 hours of exposure.
- Acetylcysteine PO/IV
- Hepatic cell binding inhibitor
- Diminishes hepatic necrosis
Past the 8 hour window to use acetylcysteine for APAP toxicity, your last resort is (), and it is also used in patient demonstrating signs of ()pathy
- Last resort: Extra-corporal excretion
- Used in signs of hepatic encephalopathy, such as AMS/neuro deficits.
altho i feel like the algo says give AC
You should request an serum APAP level as your immediate next step if APAP ingestion occurred after more than () hours.
4
Less or unknown = consider GI decontamination!
Gastric lavage/activated charcoal
T/F: All patients undergoing acetylcysteine therapy for APAP toxicity must be admitted.
TRUEEE
You should not expect LFTs to be elevated in APAP toxicity until how long?
Give it like a day or 2 at least
2-3 days is stage 2!
The MC lab finding you would prob see in ETOH toxicity is…
Hypoglycemia
ETOH inhibits gluconeogenesis
You only really need a BAC if you don’t know…
How much they ingested!
Generally, a BAC of () or more is when you see reflexes/gross motor control start to take a hit in ETOH toxicity.
0.1 or higher
At a BAC of (), you would probably see noticeable changes in breathing and pulse.
0.3 or higher
IV thiamine is primarily used in ETOH toxicity if there is a ()
Hx of chronic ETOH use.
Pt presents to the ED. Was binge drinking and vomited a little. No hx of chronic ETOH abuse. No SI/HI. Pretty solid health history. His glucose is about 40. Your dispo for this patient is to….
Give some IV dextrose and observe in ED until sober and then d/c
Ingestion of () is ethylene glycol poisoning.
Antifreeze
100 mL or a 1/2 cup is a LETHAL DOSE
Ethylene glycol is processed in the liver and makes a (acid/base), eventually leading to metabolic (acid/base) and end-organ damage.
Oxalic acid, leading to metabolic acidosis
Generally, the first set of symptoms you would see in a patient presenting with antifreeze/ethylene glycol toxicity is…
CNS depression after 1 hr (like they drunk)
In just 12 hours, you will show end-organ signs
ABG for ethylene glycol toxicity should show a wide AG metabolic () and a UA can be fluoresced to show () crystals.
- High AG metabolic acidosis
- Calcium oxalate crystals
Oxalic acid
BEcause serum ethlyene glycol levels take 2 days to come back, we prefer to determine exposure amount based on serum (). A () > 50 is highly suggestive of ethylene glycol poisoning.
Serum Osmolality gap
You should only use Bicarb for alcohol toxicity if the pH is less than …
7.2
Specifically in ethylene glycol, you use one of two drugs for the metabolic blockade.
The first drug is (), which inhibits alcohol dehydrogenase and prevents breakdown of EG into its toxic metabolites.
The alternate/2nd drug is (), which is used because it has a higher affinity for alcohol dehydrogenase than EG.
- Fomepizole IV
- Ethanol
Foamy piss O (cause oxalic acid and oxalate crystals)
Besides metabolic blockade for ethylene glycol toxicity, you can do () in more severe symptoms.
Hemodialysis
T/F: B vitamin therapy for EG toxicity is very helpful.
False
If you are uncertain about if someone actually ingested EG, you shoudl watch them for () hours, making sure they have a negative ethanol, no symptoms, no osmolar gap, and no presence of metabolic acidosis
6 hours
I think its 6 hours for everything =
Besides aspirin, a common OTC drug that contains salicylate is…
Pepto Bismol
Salicylate is converted to (), which can impair gastric emptying, leading to () formation
Salicylic acid, leading to bezoar formation
Acute salicylate poisoning is DOSE Dependent:
- < 150mg/kg = (ear) + N/V
- 150-300 mg/kg = Tachy(), Hyperpyrexia, sweating, ataxia, anxiety
- 300mg/kg + = (neuro) + ()failure
Note: these are not salicylate serum levels
- < 150 = tinnitus, hearing loss
- 150-300 = tachypnea
- 300+ = AMS, seizures, heart/lung/renal failure
A salicylate level measured greater than () mg/dL is considered toxic.
30 mg/dL or more
Note that it takes 4-6 hours to peak and you check hourly until peak.
The first acid-base disorder in salicylate poisoning is (), but then it becomes ()
Respiratory alkalosis, followed by metabolic acidosis
I think of it as you start hyperventilating first, but as you convert it to salicylic acid, you get metabolic acidosis.
You need to get () imaging if you suspect bezoar formation in salicylate poisoning.
Abdominal imaging
You would suspect if level rises despite gastric lavage/charcoal
Your patient’s salicylate level is rising steadily every hour despite adequate gastric lavage and activated charcoal. Your next step in management should be…
Order abdominal imaging to check for bezoar formation
The two ways to reduce salicylate burden in salicylate toxicity is by () urine with (), or in more severe cases, doing ()
- Mod-severe: Urinary alkalinization via bicarb (FIRST-LINE)
- Severe: hemodialysis (also if renally impaired)
Bezoars can be removed…
Surgically
