Pharmacology-Poisoned Patient

Question 1

Most common cause of death in a poisoned patient

Answer 1

Trauma (MVA)

Question 2

Types of poisoning

Answer 2

Intentional (suicide and roofies), accidental (illicit drugs, kids, elderly), envenomations and terrorism.

Question 3

Tox history

Answer 3

Trauma, dosage, co-ingestions, PMH, psychiatric history, collaterals (contacts, things found on scene). If things don’t add up think about tox.

Question 4

“Septic” old people without evidence of infection

Answer 4

Salicylates

Question 5

26 year old man is slumped over his desk with a bottle of unlabeled pills in his backpack. He has a history of back pain. Physical exam shows elevated HR, T, BP, big pupils dry skin and is obtunded. ECG shows What is his toxidrome?

Answer 5

Anticholinergic toxidrome. Note the tachycardic rhythm, upright R wave on aVR (sign of Na channel blockade), wide QRS complex and long QT. This is pathogmonic for TCA overdose (amitriptyline).

Question 6

A 66 year old woman presents with abdominal pain, diarrhea and vomiting. She said symptoms came up after eating a “bean” from a roadside plant. She has a history of depression. HR is elevated, she is dehydrated, normal mental status and abdomen is very tender. What beans could cause her symptoms?

Answer 6

Castor bean (Ricin) poisoning, supportive care usually results in resolution.

Question 7

A 21 year old woman is brought in to see you after sending suicidal texts. No evidence of ingestion of poison is present. Physical exam reveals a sad appearing woman and nothing else. What lab might you pull?

Answer 7

Acetaminophen levels because overdose is clinically silent. Tx with N-acetyl cysteine.

Question 8

Tox physical exam

Answer 8

Trauma, vitals, pupils, skin, bowel sounds and mental status combined with the history will give you your “toxidrome”.

Question 9

Cocaine overdose toxidrome

Answer 9

Elevated HR, T, BP (sympathomimetic). Hyperactive mental status. Dilated pupils. Diaphoretic skin.

Question 10

Jimson weed overdose toxidrome

Answer 10

Increased HR, T, BP (anti-cholinergic). Hyperactive mental status. Dilated pupils. Dry skin.

Question 11

Opiate overdose toxidrome

Answer 11

Pinpoint pupils, bradypnea

Question 12

PCP overdose toxidrome

Answer 12

Rotatory nystagmus (also with alcohol)

Question 13

Common overdose that is clinically silent.

Answer 13

Acetaminophen

Question 14

Useful acute tests

Answer 14

Acetaminophen levels (in suicidal patients), ECG, chemistry/blood gas.

Question 15

Least useful acute tests

Answer 15

Drug levels and urine tox screens. Lots of false +, false - and may be used normally and not causing symptoms.

Question 16

Treatment principles of poisoning

Answer 16

Decontamination, gastric lavage (usually not effective), whole bowel irrigation (usually not effective), emetics (often contraindicated due to aspiration), dialysis (most effective), charcoal (good if taken within 30 min of ingestion), supportive care (fluids, electrolytes, respiratory support).

Question 17

Commonly used antidotes

Answer 17

Snake bites, scorpion stings, digoxin overdose, N-acetylcystein for acetaminophen overdose.