Poisoning Flashcards by k k

What doesn’t activated charcoal adsorb?

Metals - iron, heavy metals
Alcohols
Caustics
Lithium

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Organophosphate insecticides
Carbamate insecticides
Nerve gas
Myasthenia gravis medications
Mushrooms (not amanita)

Cholinergic

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Cholinergic Symptoms

SLUDGE - fluid from every orifice
S alivation
L acrimation
U rination
D efecation
G astrointestinal
E ye-miosis (small pinpoint)
Other...

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Antihistamines
Antipsychotics
Atropinics
Tricyclic antidepressants
Amanita mushrooms
Jimson weed, deadly nightshade

Anticholinergic substances

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Anticholinergic Toxidrome

Blind as a bat (mydriasis) - dilated pupils
Hot as a hare (hyperthermia)
Red as a beet (vasodilation)
Dry as a bone (anhidrosis)
Mad as a hatter (delirium)

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4 stages of acetaminophen toxicity

1 - 0-24 hrs - N/V, anorexia
2 - 12-24 hrs - asymptomatic
3 - 2-7 days - fulminant hepatic failure
4 - 1-2 weeks - recovery

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Rx: acetaminophen overdose

N-acetylcysteine +/- charcoal

Initiate up to 24hrs after ingestion

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Ethanol
Ethylene glycol - antifreeze
Isopropranol - rubbing alcohol
Methanol

Alcohols

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Alcohol Toxidrome

Inebriation
CNS depression
Seizures
Hypoglycemia
Miosis (variable)

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Sx methanol

Blindness, pancreatitis, fixed dilated pupils

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Sx isopropanol

Gastritis

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Sx ethylene glycol

Renal failure

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Rx: alcohol ingestion

Ethanol/isopropanol - supportive
Ethylene glycol/methanol
     >20 - ethanol
     >50 - hemodialysis
     Alternative - Fomepizole (alcohol dehydrogenase inhibitor that prevents toxic metabolites)

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Anticholinergic Rx

Charcoal
Physostigmine controversial - seizures, bradycardia, cardiac arrest
Benzodiazepines for agitation, seizures

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Symptoms of Beta-blocker ingestion

Respiratory depression
Bradydysrhythmias
Hypotension
Hallucinations
Seizures
Hypoglycemia

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Rx B-blockers

Activated charcoal
Whole bowel irrigation
Glucagon for hypoglycemia, hypoTN and bradycardia
Atropine - bradycardia
Milrinone
Epinephrine - massive doses required to overcome beta-blockade

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Ammonia > 5%
Sodium hypochlorite >5%
Laundry detergents
Drain openers

Alkali caustics

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Drain openers
Toilet bowl cleaners
Rust removers
Oven cleaners

Acid caustics

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Sxs of caustic ingestions

Mucosal burns
Pain
Drooling
Stridor
Refusal to eat or drink

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Rx Caustics

Endoscopy
Steroids? - no benefit
Airway support
Esophageal rest
Esophageal replacement
Increased risk for esophageal carcinoma with alkali (1000-3000x)

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Battery ingestion rx

Esophageal - remove
Gastric - f/u xray, 4-7days
>23mm diameter - xray - 48hrs
Persistent gastric - remove

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Sx of hydrocarbon ingestion

Dyspnea, tachypnea, hypoxemia
Wheezing, cough
CNS depression
N/V, abdominal pain

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Hydrocarbon Rx

Observation
Admit if symptomatic, abn CXR or hypoxemia
Decontamination?

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Iron toxicity

60mg/kg - moderate/severe

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Iron toxicity serum levels

500mcg/kg - severe

Sxs of iron toxicity

WBC > 15,000 Glucose >150 V/D Positive abdominal XR

4 Phases of Iron Toxicity

1 - <12hrs - N/V, diarrhea, GI bleed, rarely shock 2 - 6-36hrs - asymptomatic 3 - 12-48hr - liver failure, shock, metabolic acidosis, encephalopathy, death 4 - 4-8wks - pyloric or antral scarring and stenosis

Rx Iron Ingestion

Charcoal ineffective Emesis if <6hrs (delayed gastric emptying) Whole bowel irrigation Deferoxamine 15mg/kg/hr IV - orange/pink urine, stop when iron clears

NSAID Ingestion

``` N/V, abd pain GI bleeding Seizures Apnea Metabolic Acidosis Renal failure Hepatic failure ```

Rx NSAIDs

Activated charcoal Symptomatic therapy Dialysis not effective

Sx Opioid Ingestion

Miosis Respiratory depression CNS depression - codeine, meperidine and dextromethorphan cause CNS irritability - stupor and delerium

Rx Opioid ingestion

ABCs Activated charcoal Naloxone - half life 60-90min - don't treat and turf

Sx Organophosphates

SLUDGE | Delayed neurotoxicity - paresthesias, weakness, ataxia, personality changes, cognitive impairment

Rx Organophosphates

``` Skin decontamination Activated charcoal Supportive care Atropine Pralidoxime (2 PAM) - acetylcholinesterase reactivator ```

Sx salicylates

``` Fever N/V Tinnitus Lethargy, coma, seizures Respiratory alkalosis Metabolic acidosis Hyperglycemia ```

Dx salicylate ingestion

ABG for acid/base status | Serum level

Rx Salicylates

``` Activated charcoal Whole bowel irrigation Rehydration Alkalinization - decreases CNS penetration and enhances excretion Hemodialysis - renal failure, acidosis ```

Sx TCA

CCC - comas, convulsions, cardiac Peripheral anticholinergics - dry, tachycardia, hypertension, urinary retention (blind as a bat) CNS - confusion, agitation, lethargy, coma, seizures Cardiac - prolonged PR, QRS, QTc; heart block; torsades de points, hypotension

TCA Eval

QRS nL x 6hrs - d/c QRS >0.1s - seizure risk QRS >0.16s - dysrhythmia risk

Rx TCA

Activated charcoal Seizures - benzos or barbituates Sodium bicarbonate Ventricular dysrhythmias - lidocaine or magnesium

Antidotes = Acetaminophen

N-acetylcysteine

Antidotes = Benzodiazepines

Flumazenil

Antidotes = Digitalis

specific Fab

Antidotes = Iron

deferoxamine

Antidotes = INH

Pyridoxine

Antidotes = Narcotics

Naloxone

Antidotes = organophosphates

Atropine/Pralidoxime

Antidotes = TCA

Sodium bicarbonate

Antidotes = Ethylene glycol

fomepizole

Antidotes = Arsenic

BAL, penicillamine

Antidotes = B blockers

glucagon

Antidotes = carbon monoxide

hyperbaric oxygen

Antidotes = coumadin

Vitamin K

Antidotes = Cyanide

Sodium nitrite/thiosulfate

Antidotes = ethylene glycol/methanol/ethanol

Fomepizole

Antidotes = heparin

protamine sulfate

Antidotes = lead

BAL, EDTA, DMSA, penicillamine

Antidotes = Mercury

BAL

Antidotes = Methemoglobinemia

Methylene blue

Antidotes = narcotics

Naloxone

Antidotes = Phenothiazines

Diphenhydramine

Antidotes = Rattlesnake bite

Crotalid antivenom

Symptoms of this substance use includes: - drowsiness - decreased inhibition - lightheadedness - disorientation

Inhalants

Most common fatal complication of inhalant use

Cardiac arrhythmia

Most common effect of chronic inhalant abuse

Encephalopathy

Tachycardia Tremulousness HTN Mydriasis

Cocaine

Disinhibition and agitation Hallucinations Generalized muscle weakness Nystagmus

Volatile inhalants

Combative Tachycardia Mydriasis

Amphetamines

Combative | Both vertical and horizontal nystagmus

PCP

Dry mouth Dilated pupils Drowsiness Distortion of time

Marijuana

Gynecomastia

Chronic marijuana use