ORALS - TOX Flashcards
TOX PRE-START
- PPE / MOVID
resus team, RT
appropraite PPE
portable CXR/AXR, EKG
BW: baseline (CBC, ext lytes, VBG+lactate) PLUS
LFTs, bilis
Serum Os, acetaminophen, salicylates, ethanol
Levels
will repeat bloodwork in acute ingestions Q2H - DECONTAMINATE
AC if less than 1H (and NOT PHAILS) => 50g PO X1 (0.5mg/kg peds) within 12h
WBI (IF applicable) 500cc/hr PEG
=> adults 2L/hr
=> 6-12yrs 1L/hr
=> less than 6 500cc/hr - ENHANCED ELIMINATION
MDAC - 12.5g PO Q1-2H (ABCDQ)
**Urinary alkalinization **
=> target urine PH 8.0 / serum PH 7.55
=> 3amp bicarb in 500cc of D5W => 250cc/hr
=> indications: methotrexate, ASA
hemodialysis (IV STUMBLED)
isopropyl alcohol
valproic acid
salicylates
theophylline
uremia
methanol, metformin, methotrexate
barbituates, BB (SATAN)
lithium
ethylene glycol
dabigatran - Consults
Toxicology
ICU - Antidotes / management
Follow up questions
1. indications for WBI (Shit LIMBS)
Sustained release
Lithium
Iron
Metals - Fe
Bezoar, BB, body packers
Slowly dissolving - concretions, paint chips
other: CCB, TCA
- What meds does AC not work on?
PHAILS - pesticides, heavy metals, acids, iron, lithium, solvents - When can you use MDAC (ABCDQ)
Aminophylline, ASA
Barbituates
Carbamazepine
Dapsone, digoxin
Quinine
BUPROPRION CASE
mgmt
1. treat agitation (benzos)
2. treat seizures (keppra, benzo, propofol)
3. treat hypotension - IVF
4. Intralipid
5. ECMO
FOLLOW UP
1. What is the mechanism of bupropion
inhibits dopamine norepinephrine
cardiotoxic (inhibits gap junctions) @ 10g
ACETAMINOPHEN CASE
- PPE / MOVID
resus team, RT
appropraite PPE
BW: serum OSM, acetaminophen level (4H), salicylates, ethanol, LFTs
portable XR, EKG - Management -
use rumack Matthew nomogram if btwn 4-24h of ingestion
Toxic ingestion? 150ug/mL
NAC (21H) infusion
==> 150mg/kg 1h => 50mg/kg 4h => 100mg/kg /16H - Calculate if massive ingestion
g/kg (1g/kg)
double 3rd bag of NAC
HD
fomepizole - Consult Tox, ICU, hepatology (if liver damage)
**follow up questions: **
1. indications to start NAC
APAP 4H on / above nomogram line (150ug/mL)
Toxic dose (150mg/kkg) + no APAP + 8hrs
present more than 8H post ingestion
time of ingest unknown => AST up / APAP detectable
- Indications for dialysis
massive OD
hepatorenal syndrome
PH 7.3
encephalopathy
lactate >3.5
levelated level >1000 - Metabolism of APAP
Glucuronidation
Sulfation
Metabolized by CYP 2E1 to NAP1I
=>inducers: phenobarbital, INH, dilantin, rifampin
=> hepatic depletion of glutathion (chronic ETOH, liver dz, tylenol use)
Elimination (urine) - Describe mechanisms of NAC
glutathione precursor
glutahione substitute
enhancement of sulfation
binds NAPQI
free radical scavenger
incr NO synthase (improves O2 delivery)
changes hepatic microcirculation
decr cerebral edema, hypotension + death - How do you progsnosticate risk of death or liver transplant
King’s college criteria (pH 7.3, all 3: Cr 300, INR 6.5, Grade 3 encephalopathy)
Apache socre >20 - Describe when you can’t use the Rumack Matthew Nomogram
outside the 4-24H window
sustained release
unknown ingestion time
IV acetaminophen
CO-ingestion that would delay absorption - Stages of tylenol toxicity
Stage 1: pre injury (0-12H, 1d)
GI symptoms, APAP level
Stage 2: liver injury (8-72H, 2D)
RUQ pain, AST up
Stage 3: fulminent hepatic failure, (2-4D, 3D)
liver failure, encephalopathy, DIC, ARDS, MOF
Stage 4: recovery (4D)
complete histologic recovery or death
ANTICHOLINERGIC CASE
- PPE / MOVID
resus team, RT
appropraite PPE
BW: serum OSM, acetaminophen level (4H), salicylates, ethanol, LFTs
portable XR, EKG (look for TCA) - Management
within 1H order 1g/kg AC
supportive: cooing, IVF
benzos (agitation)
physostigmine 1-2mg IV / 5min
follow up questions
1. Typical anticholinergic presentation
mad as a hatter
hot as hades
blind as a bad
dry as a bone
red as a beet
tachycardia
urinary retention
- drugs/plants that contain anticholinergics
TCA
scopolamine, glycopyrrolate
atropine
benadryl, gravol
deadly night shade, jimpson weed - Contraindications to physostigmine
TCA OD + CV instability
widened QRS
bradycardia (AV block)
acute closed angle glaucoma
BETA BLOCKER / CALCIUM CHANNEL BLOCKER CASE
CONSULTS
- toxicology
- ICU +/- HD
1ST PHASE:
1. Decontamination: AC, WBI, MDAC
2. 2L IVF
3. Atropine 1mg Q3min
4. Calcium 1-2g then infusion
5. Consider glucagon (incr cAMP = incr Ca influx = incr inotropy)
2ND PHASE:
1. High dose insulin 1U/kg => 0.5U/kg/hr
2. accucheck Q15min, rpt VBG for K q1h
3. D50 if Glc less than 11
4. HD: SATAN drugs
5. early cardiac pacing
3RD PHASE:
1. Intralipid 1.5cc/kg of 20% solution over 2min x1 in 5min
2. IABP
3. ECMO
4. methylene blue
if Ventricular tachydysrrhythmias
1. defibrillation (likley won’t work)
2. Na Bicarb amps (if wide)
3. Lidocaine 1.5mg/kg
4. DO NOT give amio / procainamide
**FOLLOW UP QUESTIONS **
- What are special considerations to consider for peds
symptomatic hypoglycemia common in peds, obtunded peds (empirically get dextrose => consider infusions)
seizures are uncommon - What’s up with sotalol
blocks cardiac K channels =QTC prolongation / torsades
mgmt: MgSO4, correct electrolytes, if HR 100 give isoproterenol, or overdrive pacing (HR 100-120) - What’s up with propranolol
Na channel blockade (QRS prolongation)
can cause seizures, decr LOC
mgmt - NaBICARB - Which CCB cause heart failure
verapamil
diltiazem
CAUSTICS CASE
- PPE / MOVID
resus team, RT
appropraite PPE
BW: serum OSM, acetaminophen level (4H), salicylates, ethanol, LFTs
portable CXR + AXR, ECG
things to avoid:
AC
emetics
neutralizing agents
gastric lavage
follow up questions
1. Elements that determine severity of caustic injury
type of agent
concentration
pH
viscosity
volume
duration of contact
presence or abscess of food
- Grades of caustic injury
1 - edema + hyperemia
2 - superficial ulcers, exudates, friable tissue
3 - full thickness, risk of perf and strictures
CHEMICAL INJURIES CASE
- PPE / MOVID
resus team, RT
appropraite PPE
BW: Mg level, serum OSM, acetaminophen level (4H), salicylates, ethanol, LFTs
portable XR, EKG
analgesia - MGMT
=> Decontaminate: irrigate, debride blisters, remove nails
=> calcium therapy
3g calcium gluconate + 150cc lube
intradermal injection
IV injection with Bier block
intraarterial
nebulized (if inhaled)
=> treat electrolytes (look for on EKG)
hypoCa (prolong QTC - ST segment long)
hypoMg (prolong PR, QTC)
hyperK treat
=> ocular invovlement
optho emergency
flush eye with irrigation (morgan lens, anesthetic)
assess for globe rupture + glaucoma
DIGOXIN CASE
- PPE / MOVID
resus team, RT
appropraite PPE
BW: DIG LEVEL, Mg level, serum OSM, acetaminophen level (4H), salicylates, ethanol, LFTs,
portable XR, EKG
call poison control - MGMT
digifab at the appropriate dose
=> cardiac arrest 20 vials
=> malignant dysrhythmias 10 vials
=> acute stable 5 vials
=> chronic unstable 6 vials
=> known mg: #vials = (mg x 0.8)x2
additional tx:
treat hyperkalemia
atropine 0.5mg if brady
electrical cardioversion (@ lower energy due to incr automaticity)
lidocaine 1.5mg/kg - Disposition
ICU admission
follow up questions
1. Indications for digibind
unstable PLUS 1) bradyarrythmias 2) cardiac ingestant
dysrhythmias PLUS 1) ventricular OR 2) plant ingestant
progressive rhyhtm
K >5, rising K
ACUTE ingestion >10mg PLUS aboe
LEVLE >6ng/mL PLUS above
- EKG changes of dig toxicity
therapeutic
Sagging ST segment depression
Flattened T waves
Inverted / biphasic t waves
Shortened QTC
toxicity
Biventricular VT
slow afib / flutter + slow ventricular rate
junctional tachycardia (70-130)
atrial tachy w block (atrial rate ~150-200)
PVC
AVB / SA block
sinus brady / tachy
junctional escape
torsades
v fib - Evidence of a toxic ingestion
ventricular dysrhythmia, significant bradycardia
K >5, rising K
progressive dysrhythmia
co-ingestion of cardiac drug or cardiac glycoside plant
HYDROCARBON CASES
- PPE / MOVID
resus team, RT
appropraite PPE
dermal decontamination
BW: levels, co-oximetry
portable CXR, EKG
analgesia - MGMT
+/- intubation (HC are airway irritants), consider ECMO (ARDS)
dysrhythmias:
DON’T give epi (myocardium is sensitized to catecholamines, precipitating ventricular dysrhythmias / death)
lidocaine 1.5mg/kg
BB: esmolol 500mg/kg/1min
cardioversion: low voltage 50J - DISPO
if asymptomatic - monitor for 6H, needs normal XR (if pneumonitis - hospitalize for O2 + monitoring)
Follow up questions
1. name 5 things that contain HC
Aliphatic petroleum - gasoline, propane, butane, paint thinners
Aromatic - toluene, benzene
Halogenated - methylene chloride, freon
- List characteristics of toxic HC
Low viscositiy
high volatility
low surface tension
side chains - Affect of HC on the body
Lungs: direct damage, simple asphyxiant, irritation + bronchospasm, inhibiti surfactant
Heart: dysrhythmias, hypotension
AMS - Indications for GI decontamination (CHAMP)
Camphor - neurotox, seizures
Halogenated - sudden sniffing death, dysrhyhmias, centrilobar hepatinc necrosis
Aromatic - BM suppress, leukemia
Metals - arsenic (Hg, Pb), neuro tox
Pesticides - cholinergic, seizure, resp depression
INHALED TOXINS CASES
other sources: engine exhaust, pain thinners
(patient in a housefire)
- PPE / MOVID
resus team, RT
appropraite PPE
BW: levels, co-oximetry
portable XR, EKG
analgesia
call poison control - MGMT
100% FiO2 on NRB +/- intubation
tdap, ABX
CO mgmt: 100% FiO2, HBOT (incr dissolved O2 in blood and competes with CO on RBC)
CN mgmt: hydroxycobalamin 5g, Na thiosulfate 12.5g - Consults
Toxicology
ICU
Plastics
FOLLOW UP QUESTIONS
1. Indications for HBOT in CO
15% (preg), 25% (Everyone)
incr level and AMS, seizure, coma, myocardial ischemia
- How does CO cause poisoning
forms COHb + can’t carry O2
binds myoglobin = atraumatic rhabdo
inhibits cytochrome 4
free radical injury, lipid peroxidation - Examples of things that incr vs decr O2 affinity
INCR: high PH, low temp, fetal HgB, met-Hgb, CO-HgB
DECR: low PH, high temp, high 2,3 DPG, incr CO2 - Presentation of CN toxicity
AGMA, high lactate - Methemoglobinemia
dapsone, methylene blue, nitrites, nitriles, antimalarials (quinine), lidoaine, benzocaine, sulfa drugs
methylene blue 1-2mg/kg
alternative: hyperbaric O2, exchange transfusion
CLINICAL - cyanosis (classic SpO2 85% not responsive to O2, chocolate brown blood)
MGMT:
Co-oximetry w methemoglobin level
ABG - normal / high PaO2, SaO2 100% on gas, low SpO2
methylene blue 1-2mg/kg over 5min
(not in G6PD => exchange transfusion instead)
IRON TOXICITY
- PPE / MOVID
resus team, RT
appropraite PPE
BW: 3H iron level (rpt 6H post ingestion), type and screen, CBC/smear, INR/coag
elevated wBC, hyperglycemia
portable CXR+AXR, EKG
analgesia
call poison control - MGMT
Decontamination
=>AC won’t work (PHAILS)
=> WBI (500cc/hr (6) 1L/hr (6-12), 2L/hr via NG until rectal effluent + AXR are clear)
Deferoxamine (chelates Fe) 15mg/kg/hr (max 24H)
to remember: 20mg/kg = WBI, 60mg/kg = deferoxamine, >90umol/L = deferoxamine
Last ditch:
Consider dialysis post deferoxamine (ferrioxamine is dialyzable)
Consider exchange transfusion (if level >180) - Consults
Toxicology
+/- nephrology for HD
+/- ICU
Follow up questions
1. indications for deferoxamine
systemic toxicity
serum level >90umol/L
ingested >60mg/kg
- List complications of deferoxamine
hypotension
ARDS
yersinia sepsis
anaphylactoid reaction
ototoxic + visual toxicity
pink urine - indications for WBI
See on AXR
ingestion >20mg/kg - Describe the stages of Fe toxicity
1 - (6H) - GI (N/V GIB, corrosive)
2 - (12H) - latent (acidosis, CNS down, cellular tox)
3 - (24H) - sytemic (GIB, coag, acidosis, renal failure)
4 - (1wk) - hepatic (fulminent liver failure)
5 - (1mo) -obstructive (pyloric, bowel scarring) - Content of Fe
ferrous gluconate (10)
ferrous sulfate (20)
ferrous fumarate (30) - When to dc deferoxamine
patient well
normal acid base
urine not color changing
AXR = no more pills
LITHIUM CASE
- PPE / MOVID
resus team, RT
appropriate PPE
BW: standard tox bloodwork PLUS lithium level
portable CXR+AXR, EKG
call poison control - MGMT
**Decontamination **
=>AC won’t work (PHAILS)
=> WBI (20cc/kg/hr, 2L/hr via NG until rectal effluent + AXR are clear)
**Enhance elimination **
IVF with goal of euvolemia - monitor UO
Consider HD - Consults
Toxicology
admission
+/- dialysis
FOLLOW UP QUESTIONS
1. Indications for hemodialysis
acute level >4 / chronic >2.5
renal insufficiency
can’t eliminate with volume expansion 2’ overload (cirrhosis, HF, pancreatitis)
clinical deterioration (seizures, decr LOC, dysrhythmias)
- Describe effects of lithium (LITHIUM)
Leukocytosis
DI
tremor
hypothyroidism, hyperCa
increased weight
N/V/diarrhea - Patient goes to dialysis and his levels come down. He is returned back to ED and pending discharge. A repeat level shows that they are climbing again. What is going on?
REBOUND phenomenon (chronic toxicity - plasma levels decr, lithium is released from body stores = incr level)
ORGANOPHOSPHATE CASE
(cholinergic toxicity picture)
PATIENT presentation: cholinergic toxicity
- PPE / MOVID
resus team, RT
appropraite PPE
BW: standard tox bloodwork
portable CXR+AXR, EKG
call poison control - MGMT
**External decontamination **
=> remove all clothing, seal tight in bag
=> soap + water
reverse acetylcholine excess (give anticholinergic)
=> atropine 2mg IV x2dose Q5min
prevent aging:
=> 2-PAM 2g IV / 30min - Consults
Toxicology
admission
follow up questions
1. describe cholinergic presentations
dumbell - diaphoretic, urination, miosis, bronchorrhea, bradycardia, emesis, lacrimation, lethargic
- What is the mech of organophosphate toxicity
Cholinergic toxicity from ACH esterase inhibition = ACH build up
(to fix this = anticholinergic) - List indications to stop atropine
resperations dry out
breathing better
RR normal - Indications to give 2PAM
Resp depression / apnea
fasiculations
seizures
arrythmia
CV instability
using >4mg atropine
SALICYLATE CASE
- PPE / MOVID
resus team, RT
appropraite PPE
BW: standard tox bloodwork
rpt ASA level q2H until level less than 2.2
portable CXR+AXR, EKG
call poison control - MGMT
decontamination
within 1H = AC 50g (consider MDAC if massive / WBI)
alkalnize urine
3amps NaBicarb / 1L of D5W as infusion @ 2x maintneance
foley for urine PH and ins and outs
GOALS
urine PH = 8
serum PH 7.5-8
UO 2-3cc/hr
Fluid resuscitate
avoid hypokalemia (goal = 4.5) - prevents alkalnization
replace GLC
Elimination
consider HD - What is the cause for hypokalemia
vomiting
incr excretion 2’ resp alkalosis
AKI
inhibition of transport system 2’ uncoupling of oxidative phosphorylation - Indications for hemodialysis
level >7.2 (acute) / 2.9 (chronic)
rapidly rising levels
deteriorating condition
CNS - AMS, coma, seizure
RS - pulm edema, intubated
hepatic, renal failure
other dialysis indications (acid / base, volume)
pregnant - When to stop treatment
2 levels that show salicylate is decreasing
salicylate level less than 40mg/dL
asymptomatic with normal respiratory rate - Indications for urinary alkalnization
salicylate level >2.2
rapidly rising levels
sig acid - base disturbances
proven / suspected toxicity w symptoms of salicylate OD
SEROTONIN SYNDROME /NMS CASE
- PPE / MOVID
resus team, RT
appropraite PPE
BW: standard tox bloodwork
portable CXR+AXR, EKG
call poison control - MGMT
supportive - cooling, benzos, IVF
SS:
cryptoheptadine 12mg PO then 2mg q2H
stop offending medications
treat HTN (consider nitro)
CT brain
NMS:
Dantrolene 2.5mg/kg
bromocriptine 5mg
ECT
follow up questions
1. describe the hunter criteria
On serotonergic agent / washout
PLUS 1:
1) spontaneous clonus
2) inducible clonus + diaphoresis OR agitation
3) ocular clonus + diaphoresis OR agitation
4) inducible clonus + hyperTHERMIA + hyperTONIA
5) ocular clonus + hyperTHERMIA + hyperTONIA
6) hyperreflexia + tremor
- Diagnostic criteria for NMS (HERACS)
Hyperthermia >38
Exposure less than 72H dop antagonist / withdrawal from dop agonist
Rigidity
AMS
CK elevation (x4 ULN)
Sympathetic NS lability (elevated BP, sweaty, pee yourself, hypermetabolic, neg w/o for other tox) - What is the difference btwn SS + NMS
SS - serotonergic agent, CLONUS, HYPERREFLEXIC, DILATED pupils
NMS - Rigid, NORMAL REFLEXES, NORMAL pupils - List drugs assocaited with serotonin syndrome
tramadol
demerol
SSRI
SNRI
Buproprion
Lithium
Fentanyl
Methadnoe
Carbamazapine
