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Environmental > Overdose and Poisoning > Flashcards

Overdose and Poisoning Flashcards

1
Q

Routes for poisoning

A
  • Ingestion (most common)
  • Inhalation
  • Injection
  • Transdermal
  • Ocular
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2
Q

Tox physical exam should have a special emphasis on

A
  • Mental Status
  • Pupil size
  • Skin temp
  • Sweating or not
  • Muscle tone
  • Gi motility and mucus membrane
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3
Q
  • Collection of signs and symptoms that are observed after an exposure to a substance
  • It includes grouped abnormalities of vitals, appearance, skin, eyes, mucus membranes, lungs, heart, abdomen, and neurological examinations.
A

“Toxidrome”
“Toxic fingerprint”

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4
Q

Studies helpful for poisoning

A

1) Glucose
2) EKG
3) Blood gas
4) Electrolytes
5) CBC
6) Alcohol levels
7) Pregnancy testing

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5
Q

If a poisoned/overdosed patient has altered mental status, what medications should be given?

A
  • Naloxone 0.2mg IV/IM/SQ every 2 to 3 minutes. 15 mg max
  • Glucose (dextrose) 50ml bolus (25gm glucose)
  • Thiamine 250mg IV/IM once daily
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6
Q

What is the most common form of GI decontamination for poisoning/overdose

A
  • Activated charcoal
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7
Q

Disposition for Overodse/Poisoning

A
  • MEDEVAC
  • Referred to psychiatric evaluation
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8
Q

Dry as a bone, red as a beet, hot as a hare, blind as a bat, mad as a hatter and stuffed as a pipe

A

Anticholinergic toxidrome

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9
Q

What commonly causes Anticholinergic toxidrome

A

Antihistamines (primarily diphenhydramine), phenothiazines, muscle relaxers, antidepressants, and Jimson weed

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10
Q

Sx:
- Absent bowel sounds
- Mydriasis
- Hyperthermia
- Dry skin/mucus membranes
- Urinary retention
- Confusion/agitation
- Tachycardia
- Flushed skin
- commonly acutely agitated however not typically aggressive and violent as compared to sympathomimetic patients
- common EKG finding is sinus tachycardia. Also wide complex tachycardia and prolonged QT interval can be seen.

A

Anticholinergic overdose

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11
Q

Emergency care for anticholinergic overdose

A

(5) Emergency Care
(a) Mostly supportive
(b) IV, O2, monitor
(c) GI decontamination with Activated charcoal (may be useful even if greater than 1 hour due to delayed GI motility)
(d) Treat hyperthermia and seizures (Benzodiazepines)
(e) If acutely agitated - benzodiazepines
(f) MEDAVICE/MEDEVAC

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12
Q

Examples of SSRIS

A

Fluoxetine, Sertraline, Paroxetine, Fluvoxamine, Citalopram and Escitalopram.

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13
Q

Most serious adverse effect of SSRI

A

Serotonin syndrome

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14
Q

SSRI has what kind of therapeutic to toxic ratio

A

High therapeutic to toxic ratio

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15
Q

Emergency care for SSRI overdose

A

(a) Supportive care generally all that is required (IV, O2, Monitors, MEDEVAC/ADVICE)
(b) If symptomatic gain IV access and place on monitors and discuss with higher echelon.
(c) Treat seizures with benzodiazepines and EVAC

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16
Q

What is serotonin syndrome

A
  • Potentially fatal adverse drug reaction to serotoninergic medication, characterized by autonomic and neuromuscular dysfunction
  • Can be caused by a single drug or combo of medications that increase serotonin transmission
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17
Q

(3) Clinical Features:
(a) Cognitive and behavioral - confusion, agitation, coma, anxiety, hypomania, lethargy, seizures
(b) Autonomic - hyperthermia, diaphoresis, tachycardia, hyper/hypo tension, dilated
pupils, salivation
(c) Neuromuscular - myoclonus, hyperreflexia, rigidity, tremor, ataxia, shivering, nystagmus
(d) Diagnosis is made clinically after excluding other psychiatric or medical conditions.

A

Serotonin Syndrome

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18
Q

Emergency care of serotonin syndrome

A

(a) D/C all serotoninergic agents and provide supportive care
(b) MEDEVAC
(c) Monitor all patients with muscle rigidity, seizures or hyperthermia for rhabdomyolysis.
(d) For muscle rigidity or seizures administer benzodiazepines

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19
Q

How common is death from Benzodiazepines isolated use?

A

Rare, but combined with sedative/hypnotic/opioids can cause morbidity to increase

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20
Q

Ingestion of benzos and barbituates can cause what sx

A
  • Dizziness, slurred speech, confusion, ataxia.
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21
Q

Most common vital sign abnormality of barbiturates and benzodiazepines

A

Respiratory depression

22
Q

Emergency care of barbiturates and benzodiazepines

A

(a) Assess and stabilize ABC’s
(b) Airways management and ventilator support may be required in the obtunded patient
(c) Activated charcoal may decrease absorption and should be administered to the cooperative patient presenting within 1 hour of ingestion
(d) Flumazenil/Romazicon - limited role
(e) Call MO/Poison control 1-800-222-1222
(f) MEDEVAC

23
Q

What is a benzodiazepine antagonist and not routinely used

A

Flumazenil

24
Q

Flumazenil contraindications

A

a) Benzodiazepine dependence
b) Ingestion of seizure inducing agent
c) Known seizure disorder

25
Q

Emergency care for ethanol

A

(a) Mainstay is observation and supportive care
(b) Exclude hypoglycemia with glucose level
(c) IV fluid are generally not required unless patient appears clinically dehydrated
(d) Observe until sobriety is reached and patient is not a harm to self
(e) Complicating injuries must be excluded and a deterioration or worsening condition through observation should prompt an evaluation for further causes

26
Q

Opiods are agonist on what 3 primary receptors

A

Mu, kappa, delta

27
Q

What are mu receptors

A

responsible for analgesia, sedation, respiratory depression and cough suppression

28
Q

(2) Clinical features
(a) CNS depression
(b) Miosis
(c) Respiratory depression
(d) Bradycardia
(e) Hypothermia
(f) Death may result from respiratory arrest (especially when combined with benzodiazepines)

A

Opioids

29
Q

Emergency care for opioids

A

(a) Airway and ventilator support are most important considerations
(b) Activated charcoal - considered if ingestion is less than 1 hour
(c) Naloxone (Narcan) - competitive agonist at all opioid receptors

30
Q

causes sympathetic nervous system activation which causes typical mydriasis, tachycardia, hypertension and diaphoresis.

A

Cocaine

31
Q

similar effect to cocaine. Block re-uptake of catecholamines, also have effect on serotonin release which causes hallucinogenic effect

A

Amphetamines

32
Q

Clinical features
(a) May demonstrate psychomotor agitation
(b) Mydriasis
(c) Diaphoresis
(d) Tachycardia
(e) Tachypnea
(f) Hypertension
(g) Hyperthermia
(h) AMS
(i) Watch for seizures and rhabdomyolosis
(j) May have chest pain, headache, dyspnea or focal neuro complaints
(k) low doses can produce coronary vasoconstriction leading to chest pain (exacerbated by cigarette smoking)

A

Cocaine, Amphetamines, Stimulants

33
Q

Emergency care Cocaine, Amphetamines, Stimulants

A

(a) Mainstay of treatment is adequate sedation and continuous monitoring of vital signs.
(b) Monitor for signs of rhabdomyolosis, cardiac complications and manage acute agitation.
(c) Obtain EKG
(d) Benzodiazepines will often improve tachycardia, hypertension and agitation
(e) Active cooling
(f) Treat seizures with benzodiazepines
(g) Treat cardiac chest pain with ASA, Nitro, Benzo

34
Q

What medication is contraindicated in cocaine use

A

beta blockers

35
Q

One of the oldest medications with continued use in clinical practice

A

Salicylates

36
Q

ASA toxicity causes respiratory alkalosis due to a direct effect on the

A

medullary respiratory center

37
Q

Salicylates blood levels

A

1) 150mg/kg - mild - N/V GI irritation
2) 150-300mg/kg moderate - vomiting, tachypnea, tinnitus, sweating
3) > 300mg/kg - severe

38
Q

(b) Symptoms include:
1) Tachypnea
2) Tinnitus
3) N/V
4) Acid base abnormalities
5) AMS
6) Pulmonary edema
7) Arrhythmia
8) Hypovolemia
9) Thrombocytopenia
10) Hepatic effects

A

Salicylates

39
Q

Emergency care for Salicylates

A

1) Emergent priorities Airway, breathing, Circulation, Cardiac monitoring, IV access
2) Administer activated charcoal 1gm/kg to minimize absorption
3) IV fluids (NS/LR) for volume depletion due to Nausea and Vomiting
4) Check glucose and administer supplemental glucose if low (maintain above 80)
5) If available on specific platform administer Sodium Bicarbonate 1- 2mEq/kg and arrange for MEDEVAC. This causes alkalization of urine and increase Salicylate elimination.
6) Discuss with higher echelon/SMO for specific treatment regimen.
7) Maintain continuous cardiac monitoring
8) Patients may ultimately require hemodialysis

40
Q

Acetaminophen maximum dose and toxicity dose

A

Maximum recommended daily dose in adults is 4gm. However, toxicity is possible to occur with single ingestion > 140mg/kg or greater than 7.5gm/24
hours

41
Q

Who is at a higher risk for acetaminophen toxicity

A

alcoholics

42
Q

Stage 1 Acetaminophen poisoning

A

first 24 hours - nonspecific. N/V, malaise, anorexia

43
Q

Stage 2 Acetaminophen poisoning

A

day 2-3 - N/V may improve and evidence of toxicity may develop. RUQ pain, elevated bilirubin/jaundice

44
Q

Stage 3 of acetaminophen poisoning

A

day 3-4 - progression to hepatic failure. Lactic acidosis, coagulopathy, renal failure, encephalopathy, N/V

45
Q

Stage 4 of acetaminophen poisoning

A

those who survive will begin to recover

46
Q

Emergency care for acetaminophen poisoning

A

(a) Priorities remain Airway, Breathing and Circulation, cardiac monitoring and IV
access
(b) NAC (N-acetylcysteine) - specific antidote for APAP toxicity. Can prevent toxicity in administered within 8 hours of ingestion. However, still beneficial if
given after this timeframe.
(c) If there is delay in obtaining APAP level empirically begin NAC treatment (i.e operational, shipboard)

47
Q

NAC dosage

A

1) Oral, NG tube 140mg/kg loading dose, followed by 70mg/kg Q4 hours for 17 additional doses.
2) IV, 150mg/kg loading dose, followed by 50mg/kg over the next 4 hours, then 100mg/kg over next 16 hours. Ideally initiate loading dose and medevac to higher echelon under consultation with poison control and MO.

48
Q

The term _____ refers to the irreversible binding of compound to the cholinesterase.
Antidotes are ineffective once this occurs

A

Aging

49
Q

(a) SLUDGE
1) Salivation
2) Lacrimation
3) Urinary incontinence
4) Defecation
5) GI pain/dismotility
6) Emesis

A

Insecticides (malathion, parathion) Nerve agents (VX, sarin)

50
Q

Emergency care of Insecticides (malathion, parathion) Nerve agents (VX, sarin)

A

(a) Decotamination
1) PPE
2) Wash patient with soap/water
3) Handle and dispose of run off
4) Handle and dispose of hazardous waste
5) Monitoring VS
6) Cardiac monitoring, pulse ox, supplemental O2
7) No benefit to gastric lavage, AC, urinary alkalinazatio

51
Q

Medication for Insecticides (malathion, parathion) Nerve agents (VX, sarin)

A
  • Atropin** 1 mg in adult. Repeat Q 5 min until respiratory secretions improve
  • Pralidoxine – 2-PAM. Should NOT be administered without concurrent Atropine.
    Treats neuromuscular dysfunction

Environmental (12 decks)

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