Poisoning Roop/Jaffe Flashcards
A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp. rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal- what are you trying to rule out here?
Stroke, tumor, brain bleed, etc.
A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal. CSF examination was normal. Electromyography showed nerve conduction velocity and amplitude to be normal, however NMJ (neuromuscular junction) impaired. What is an EMG and what is it able to diagnose?
Electromyography
Nerve/muscle conduction and muscle function
What can you expect from a nerve conduction study?
A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal. CSF examination was normal. Electromyography showed nerve conduction velocity and amplitude to be normal, however NMJ (neuromuscular junction) impaired. The Edrophonium (Tensilon) test appeared normal. What is edrophonium and what do you hope to rule out with this test?
Its a muscle strengthener
Can rule out myasthenia gravis (MG)
How is a Tensilon Test given? Why is atropine needed on hand?
Atropine is needed on hand because Ach is apart of the parasympathetic NS → decreases HR and constricts airway/bronchioles
-Ach is a part of the SNS and controls skeletal m.
-Ach is also a part of ANS under the parasympathetic division
What happens if muscle strength is improved with a Tensilion Test? What happens if its not improved?
A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal. CSF examination was normal. Electromyography showed nerve conduction velocity and amplitude to be normal, however NMJ (neuromuscular junction) impaired. The Edrophonium (Tensilon) test appeared normal. Upon further discussion with the patient, he states that on the day before he ate some green beans that were canned at home by his friends. So what’s the diagnosis?
Botulism
A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal. CSF examination was normal. Electromyography showed nerve conduction velocity and amplitude to be normal, however NMJ (neuromuscular junction) impaired. The Edrophonium (Tensilon) test appeared normal. Upon further discussion with the patient, he states that on the day before he ate some green beans that were canned at home by his friends. Doctor now thinks it’s botulism. Stool sample was positive for Clostridium botulinum. What type of organism is C. botulinum? How many different types of Clostridia are there?
-Gram-positive bacteria
-Anaerobic bacillus
-Spore-forming
-Produces the neurotoxin botulinum
-Theres 12 types
-People can still die from this because of home canning
Describe what happens at a motor neuron when an action potential arrives at the presynaptic terminal?
-Calcium influx
-Snare proteins helps vesicles to fuse to the presynaptic membrane
-In the case of botulinum toxin, it destroys Snare proteins → vesicles can’t fuse → no Ach release/exocytosis → cannot bind to receptors → flaccid paralysis
At the NMJ, ACh is stored in the vesicles of the presynaptic terminals. After the AP arrives, ________ enters the terminal causing the vesicles to migrate to the membrane.
calcium
The SNAP-SNARE proteins allow __________ of the vesicles with the cell membrane, fusion and then exocytosis of the ACh into the synaptic cleft
docking
BoNT- botulinum toxin destroys ____ of the family of proteins. ACh is not released and flaccid paralysis occurs
1+
Botulinum toxin will result in flaccid paralysis that first occurs in the _______ muscles and is symmetrical, and then will spread to other proximal muscles and then distal muscles
cranial
What muscle is paralyzed when a patient has droopy eyelids?
Levator palpebrae superioris m.
What muscle is affected that would cause a patient to have dysphasia?
Upper esophageal m. (sphincter)
What muscles are affected that would cause a patient to have double vision?
Any of the optic muscles
What is the time for symptoms to appear after ingestion of the food-borne toxin?
In foodborne botulism, symptoms generally begin 18 to 36 hours (on average) after eating a contaminated food.
How is botulism treated?
-Doctors treat botulism with a drug called an antitoxin, which prevents the toxin from causing any more harm.
-Antitoxin does not heal the damage the toxin has already done
-Fluid intake
-Induce vomiting with medication
-Antibiotics (difficult to treat anaerobic bacteria)
-Maintain airway (depending on how bad it is)
What would happen if a patient is not treated for botulism?
The disease may progress and symptoms may worsen to cause full paralysis of some muscles, including those used in breathing and those in the arms, legs, and trunk (part of the body from the neck to the pelvis area/torso)
Will affect the diaphragm muscles, so they are unable to breathe (ventilator may be necessary)
How long would a patient have to remain in the hospital when diagnosed with botulism and why? What are you trying to achieve physiologically?
Weeks to months → until all the symptoms disappear
You want the SNARE proteins to restore
The use of __________ toxin in the field of oral and maxillofacial surgery has been continuously evolving, for aesthetic and functional indications. There are the dermatological applications of botulinum toxin for cosmetology, as well as its varied therapeutic uses and its application in temporomandibular joint surgery, masseter muscle hypertrophy, bruxism, trismus, maxillofacial traumatology, salivary gland diseases, and facial palsy, among others. This should appeal to head and neck surgeons, oral maxillofacial surgeons, ENT surgeons and dermatologists in particular, and general surgeons and dentists in general.
botulinum
What is masseter muscle hypertrophy?
-rare condition
-mostly idiopathic
-enlargement of one or both masseter muscles
-facial asymmetry
What is bruxism?
Grinding of the teeth
What is Trismus?
Lockjaw, tetanic spasms of the muscles of mastication
What is the deadliest toxin in the world?
Botulinum neurotoxin
A 26 year old male patient was admitted to the hospital because of recurrent abdominal pain for three months, which has increased tremendously in the past two days. The pain is in the umbilical and hypogastric regions and radiates to the back. The patient visited an urgent care center two months ago. He was diagnosed with kidney stones and sent home with analgesics. Vitals show normal temp. resp= 12/min, pulse= 72/min, BP= 122/74/ Pt appeared to have an anemic appearance and slight tenderness around the umbilicus region. Lab studies showed low RBCs, low hemoglobin (potential anemia), high aspartate aminotransferase, high serum total bilirubin, high serum indirect and direct bilirubin, +1 urobilinogen (should not have this). What do all these lab values mean?
Liver dysfunction
Bilirubin is the breakdown product of heme and is produced in the spleen then goes to the liver to be a part of bile
-All this bilirubin is too much, which means that there’s too much breakdown of RBCs and this can result in hemolytic anemia
A 26 year old male patient was admitted to the hospital because of recurrent abdominal pain for three months, which has increased tremendously in the past two days. The pain is in the umbilical and hypogastric regions and radiates to the back. The patient visited an urgent care center two months ago. He was diagnosed with kidney stones and sent home with analgesics. Vitals show normal temp. resp= 12/min, pulse= 72/min, BP= 122/74/ Pt appeared to have an anemic appearance and slight tenderness around the umbilicus region. Lab studies showed low RBCs, low hemoglobin (potential anemia), high aspartate aminotransferase, high serum total bilirubin, high serum indirect and direct bilirubin, +1 urobilinogen (should not have this). Total abdominal CT showed bilateral kidney stones and lymph nodes increased in size in abdominal cavity and retroperitoneally. A colposcopy was done and appeared normal. Next a gastroscopy came back with chronic non-atrophic gastritis results. What is chronic superficial non-atrophic gastritis?
-Influx of neutrophils and lymphocytes → still see fundal glands
-Epithelium shedding
A 26 year old male patient was admitted to the hospital because of recurrent abdominal pain for three months, which has increased tremendously in the past two days. The pain is in the umbilical and hypogastric regions and radiates to the back. The patient visited an urgent care center two months ago. He was diagnosed with kidney stones and sent home with analgesics. Vitals show normal temp. resp= 12/min, pulse= 72/min, BP= 122/74/ Pt appeared to have an anemic appearance and slight tenderness around the umbilicus region. Lab studies showed low RBCs, low hemoglobin (potential anemia), high aspartate aminotransferase, high serum total bilirubin, high serum indirect and direct bilirubin, +1 urobilinogen (should not have this). Total abdominal CT showed bilateral kidney stones and lymph nodes increased in size in abdominal cavity and retroperitoneally. A colposcopy was done and appeared normal. Next a gastroscopy came back with chronic non-atrophic gastritis results. Pt.’s pain began to worsen and doctors delved deeper into his history. They found that his occupation was a warehouse guard. This warehouse stores old books and the building is old. Doctors did a more extensive physical exam and found the patient’s gums to have Burton’s lines. What are these lines and what do they indicate? What tests do you do to verify?
-Sign of chronic lead poisoning
-Lead levels should be less than 10 micrograms (his blood lead level was found to be 52.8ug/dl- BLOOD TEST)
-Burton’s lines is due to precipitation of lead sulfide
»It’s a blue-purplish line on the gums
»Caused by reaction between circulating lead with sulfur ions released by oral bacterial activity, which deposits lead sulfide at the junction of the teeth and gums
-Hematological smear would show basophilic stippling of RBCs indicative of heavy metal poisoning
A 26 year old male patient was admitted to the hospital because of recurrent abdominal pain for three months, which has increased tremendously in the past two days. The pain is in the umbilical and hypogastric regions and radiates to the back. The patient visited an urgent care center two months ago. He was diagnosed with kidney stones and sent home with analgesics. Vitals show normal temp. resp= 12/min, pulse= 72/min, BP= 122/74/ Pt appeared to have an anemic appearance and slight tenderness around the umbilicus region. Lab studies showed low RBCs, low hemoglobin (potential anemia), high aspartate aminotransferase, high serum total bilirubin, high serum indirect and direct bilirubin, +1 urobilinogen (should not have this). Total abdominal CT showed bilateral kidney stones and lymph nodes increased in size in abdominal cavity and retroperitoneally. A colposcopy was done and appeared normal. Next a gastroscopy came back with chronic non-atrophic gastritis results. Pt.’s pain began to worsen and doctors delved deeper into his history. They found that his occupation was a warehouse guard. This warehouse stores old books and the building is old. Doctors did a more extensive physical exam and found the patient’s gums to have Burton’s lines, which means chronic lead poisoning. What is the treatment?
Chelating agents
-Will be excreted in urine
-Examples:
»succimer and penicillamine are given orally
»dimercaprol and edetate (EDTA) calcium disodium (CaNa2 EDTA) are administered parenterally
Lead can cross the blood brain barrier and result in what? How?
seizures
Edema = increased ICP → encephalopathy
Left untreated can result in irreversible brain damage
How does lead affect the blood?
-Can block enzymes in heme synthesis pathway → anemia
-Basophilic stippling → RNA left back in RBC (not cleared because enzyme is inhibited)
-Attaches to RBC = hemolysis is easier
The 2 enzymes that are blocked by lead in ________ __________ pathway is aminolevulinate dehydratase and ferrochelatase
heme synthesis
Basophilic stipplingIs due to Pb inhibiting the ez 5’-nucleotidase which clears….
clumps of degraded RNA
Pb attaches to RBCs membrane making hemolysis much easier– hence the increase in bilirubin levels. Additionally, it reacts with sulfur ions released due to oral bacterial activity. This deposits lead sulfide at the tooth-gum junction as…
Burton’s Lines
A 58 year old man came to the ED complaining of bleeding in his mouth. It began 24 hours ago and has been continuous even with compression. He suffered an MI 18 months ago and stopped smoking after the MI. Began exercising moderately after the MI. He started taking warfarin after MI. Vital signs show normal temp., pulse= 85/min, resp.= 18/min, BP=95/65 mmHg. Lab studies show Hct= 35% (low), stool sample test was positive for blood (likely has internal bleeding), PT was 35 seconds and PTT was 48 seconds (both high, indicating clothing dysfunction). What do his blood results indicate?
Something is wrong with clotting cascade
What are the 2 major components of hemostasis?
Platelet plug formation and clotting cascade
Bleeding of the oral mucous membranes could also indicate internal bleeding, e.g. GI system. Would this be indicated in vital signs? How?
Low BP, pulse/respiration are high because body is compensating
What are platelets also known as? What are they derived from?
Thrombocytes, derived from megakaryocytes
What is the platelet lifespan?
7-10 days
Platelet formation is regulated by the hormone ___________
Thrombopoietin
Platelets have three different types of granules. What are they and what do they contain?
Alpha
-Contains adhesion proteins like fibrinogen and vWF
Dense
-Contains bioactive amines like serotonin and histamine, and also contains nucleotides like ADP/ATP
Lysosomes
-Contains degenerative enzymes
What is the mechanism of action of warfarin?
Inhibits vitamin K clotting factors
Clotting factor II = prothrombin
A 58 year old man came to the ED complaining of bleeding in his mouth. It began 24 hours ago and has been continuous even with compression. He suffered an MI 18 months ago and stopped smoking after the MI. Began exercising moderately after the MI. He started taking warfarin after MI. Vital signs show normal temp., pulse= 85/min, resp.= 18/min, BP=95/65 mmHg. Lab studies show Hct= 35% (low), stool sample test was positive for blood (likely has internal bleeding), PT was 35 seconds and PTT was 48 seconds (both high, indicating clothing dysfunction). Upon further examination and workup, the patient is found to be on the best dose of warfarin. Medical personnel again begin to question further into his history and ask about anything additional he might be taking including any supplements. Pt reveals that he began to take garlic and ginkgo biloba supplements one month ago. What are the effects of these herbal extracts?
Garlic inhibits platelet adhesion
Ginkgo biloba
-Potentiates warfarin effects (increases activity of warfarin)
-Vasodilator (for peripheral vascular disease)
Side effects: massive headaches
Most metals that cause poisoning are in a microscopic (molecular) form when they enter your body. Heavy metals can enter your body by three different systemic routes. What are they?
1) Absorbing through your skin (subcutaneous/topical)
2) Inhaling into your lungs
3) Ingesting into your digestive tract organs (orally)
What makes intact skin a good barrier?
Has layers, and the top layer sheds off (desquamates)
Normal skin should have a neutral pH (approx 7.35)
-Moderately acidic (5.5) acid mantle
Contains sweat glands and sebaceous glands
Secretions can kill bacteria
The pigment melanin provides a chemical pigment defense against UV light
What are the regions of the integument?
Epidermis, dermis, and subcutaneous tissue
What are the layers of the epidermis of thick and thin skin?
Thick skin is only on palmar and plantar regions and contains 5 skin layers
The 5 layers are: (“come lets get sun burnt”)
-stratum basale (deep)
-stratum spinosum
-stratum granulosum
-stratum lucidum
-stratum corneum (superficial)
Thin skin does not contain the stratum lucidum layer
Classify the epidermis as a specific tissue type
Keratinized stratified squamous epithelium
What are the layers of the dermis?
Thin upper layer called the papillary dermis, and a thick lower layer called the reticular dermis
-Deep reticular layer is the “leathery part” and is about 80% of the dermis
-Papillary layer makes up about 20% of dermis
-Basement membrane separates the basal layer of epidermis from the papillary layer of dermis
Contains connective tissue, blood vessels, oil and sweat glands, nerves, and hair follicles
Follow the food or liquid from your lips to your anus identifying the organs a drop of food or liquid passes across
Start at oral cavity, the labia guards the entrance (superior and inferior labia) and vestibules (space between teeth and outer lip) > jaw > pharynx > esophagus > lower esophageal sphincter > stomach > small intestine > large intestine > colon > rectum > anus
What are the 9 abdominal regions?
