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CDM 2 Exam 3 > Lecture 3 - Management of Acute Toxicologic Emergencies > Flashcards

Lecture 3 - Management of Acute Toxicologic Emergencies Flashcards

1
Q

PK factors to consider when evaluating potential drug OD?

A
  1. Drug susceptible to Bezoar formation?
  2. Was a time-release/SR formulation ingested?
  3. Does drug have anticholinergic properties that may reduce gastric emptying
  4. If pt Hypotensive (SBP <90), see dec absorption, clearance, metabolism maybe
  5. Is drug metabolism saturable
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2
Q

Sources of False positive results for Amphetamines

A

Pseudoephedrine
Phenylephrine
Trazadone
Raniditine

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3
Q

Sources of False positive results for Benzo

A

Sertraline

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4
Q

Sources of False positive results cannabinoid

A

Ibuprofen

Naproxen

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5
Q

Sources of False positive results coke metabolite

A

“caine” anesthetics

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6
Q

Sources of False positive results Opioids

A

Rifampin
Fluoroquinolone antibiotics
Synthetic opioids may not be detected

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7
Q

If inhaled poison then…

A

get person to fresh air ASAP, start artificial respiration prn

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8
Q

If poison on skin…

A

remove contained clothing, Flood skin with water, wash with soap

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9
Q

if poison in the eye…

A

flush the open eye with room temp water for 10-15min, remove contacts

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10
Q

If swallowed poison….

A

give 2-4oz of water, seek further help

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11
Q

Using Ipecac syrup in OD?

A

no role in ANY OD situation

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12
Q

Approach to poisoning in Hospital?

A

Support airway
Manage seizures, arrthymias, electrolytes, etc
Gastric lavage = only if ingestion within last hr**

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13
Q

Activated Charcoal

A
  1. Highly absorbent that binds many toxins
  2. no effective w/ Lithium and iron
  3. given up to 6hrs after ingestion, best within 1hr
  4. use Sorbitol w/ 1st dose only
  5. don’t give at home
1-12 = 25-50g
Adults = 25-100g
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14
Q

Whole bowel irrigation

A
  1. using a PEG solution
  2. Large volume admin over 12hrs to clear GI
  3. Few risks, but little evidence suggesting benefit
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15
Q

When to use Whole-Bowel irrigation

A
  1. ingestion several hrs prior to hospital presentation
  2. Ingestion of SR or enteric coated formulations
  3. substances like iron that dont absorb to charcoal
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16
Q

Acetaminophen antidote

A

Acetylcysteine

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17
Q

Anticholinergic antidote

A

Physostigmine

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18
Q

Warfarin antidote

A

Phytonadione

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19
Q

Benzo antidote

A

Flumazenil = short duration tho

20
Q

Digoxin antidote

A

Digoxin immune fab

21
Q

Ethylene glycol antidote

A

Fomepizole

22
Q

Iron antidote

A

Deferoxamine

23
Q

Isoniazid antidote

A

Pyridoxine

24
Q

Opioid antidote

25
Acute Acetaminophen Toxicity (Time 0-24hrs after ingestion)
May sea N,V, diaphoresis but many patients are asymptomatic
26
Acute Acetaminophen Toxicity (Time 2-3 days after ingestion)
Asymptomatic ise in AST/ALT and bilirubin
27
Acute Acetaminophen Toxicity (Time 3-5 days after ingestion)
Signs + symptoms of hepatic injury 1. Jaundice, RUQ tenderness, hypoglycemia,encephalopathy, elevated INR 2. hepatic failure may progress to hepatic coma and death
28
Mechanism of Acetaminophen toxicity
w/ OD, sulfate stores are rapidly depleted and inc acetaminophen is metabolized through CYP 450 ~ 90% cleared via glucuronidation but its saturated in OD ~5% CYP450 metabolized but produces active metabolite NAPQI which is bad, it depletes glutathiones Increased NAPQI = hepatotoxicity can also see acute renal failure
29
Factors to influence risk for Hepatotoxicity w/ Acetaminophen
Inc risk in adults, dec risk in kids Pts frequently dont know they're taking excessive acetaminophen pts with induced CYP2E1 (alcoholic) = inc risk inc risk w/ dose > 10g, repeated high doses 2-6g over 24hrs, or 6g/day for 5+ days.
30
Treat pt with NAC if....
Line on Nomogram is above the Nomogram treatment line Usually stay on side of caution and start NAC
31
Always start NAC if....
time of ingestion is unknown or 8 hrs have elapsed since acute ingestion and serum acetaminophen lvl is not back if start, always finish full course of NAC
32
IV NAC dosing
Given over 21 hrs $$$$
33
Oral NAC dosing
Given over 72 hrs tastes bad $
34
CCB OD results from....
1g of Diltiazem, nifedipine or verapamil = severe symptoms acute or chronic poisoning = symptoms w/ lower doses
35
Possible Symptoms of CCB OD
Hypotension Bradycardia = none with nifedipine or amlodipine***** Hyperglycemia Symptoms usually within 1-2hrs of ingestion, delayed effect is CD or SR product
36
CCB OD treatment to stabilize pt
Give charcoal within 2hrs of ingestion Intubate Aggressive IV fluid resuscitation and place pt in reverse Trendelenberg position Dopamine infusion if SBP < 90 Atropine 1mg IVP q5min X 2 if HR < 50
37
How long within ingestion can you give Charcoal for Acetaminophen OD?
Within 4hrs
38
CCB OD treatment after pt is stabilized
Intralipid 20% 100ml IVP X 1, then 100ml/hr weaning off as signs of toxicity resolve Start regardless of HR/BP
39
2 potential mechanism for Intralipid
1. binds to lipid drugs like CCB = Lipid sink phenomenon | 2. rapid energy source to cardiac cells, increasing contractility
40
If pt will has dec HR or BP after intralipid then give...
1. IV calcium Cl (IVP -> infusion)= IVP is test dose, if HR or SBP dont inc by > 10% then move on to regular insulin 2. Regular insulin (IVP-> Infusion) = if inadequate response < 10%, move to glucagon...HR < 50, SBP < 90 3. Glucagon (IVP -> Infusion)
41
TCA OD symptoms
Neurologic = lethargy, coma, seizures CV = Tachycardia, Prolonged QRS interval ( > 160msec = predictive of severe effects), Hypotension
42
TCA OD treatment
1. Activated Charcoal 50g PO X 1...can repeat 2. Sodium bicarb 50mEq IVP X 1 Q30min IF QRS interval > 160msec, SBP < 90 or Vtach 3. Lidocaine 1g IVP X 1 IF Vtach...dont use procainamide or amiodarone as it can worsen QRS prolongation
43
Who is at risk for Acute Opioid Toxicity
1. Anyone using/abusing opioid drugs 2. pts on high dose for pain management 3. elderly 4. IV drug abuse 5. Users recently out of Detox 6. Mixing with bento + booze 7. Comorbid conditions 8. Potency of street opioids
44
Acute opioid poisoning
Respiratory depression Sedation Pinpoint pupils Absence of bowl sounds Seizures w/ meperidine or tramadol Muscle rigidity w/ Fentanyl
45
Mechanism of Naloxone
Knocks of opioids from Mu receptors
46
Opioid OD treatment
IVP dose: 0.5,2,4,8,16mg. start with 0.5, if RR < 10min after 2 min and continue until RR > 10. If methadone or SR opioid...start IV infusion of naloxone at hrs dose that is 50% of last effective bolus dose
47
rare side effects of naloxone?
Poop Agitation 1/2life shorter than most opioids so symptoms of OD can return

CDM 2 Exam 3 (13 decks)

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