Poisoning/Toxicology

Question 1

What is the “coma cocktail” that is recommended for all unresponsive patients presenting to the ED?

Answer 1

• 100% oxygen on a nonrebreather
• Blood glucose check
• Administer naloxone (or any other antidote if suspected, such as flumazenil)
• Intubate

Question 2

What four questions are essential in a toxicologic history?

Answer 2

• What was ingested?
• How much of it was ingested?
• When was it ingested?
• Why was it ingested (i.e., was it intentional or accidental)?

Question 3

The toxidrome for anticholinergics includes these signs: __________________.

Answer 3

mydriasis, flushed skin that is dry, full bladder, and no sweat

Question 4

Describe the toxidrome for cholinergic toxicity.

Answer 4

• Bronchospasm
• Salivation
• Lacrimation
• Urination
• Diarrhea
• GI upset
• Excessive bradycardia

Question 5

Go through MUDPILES.

Answer 5

• Methanol
• Uric acid
• Diabetic ketoacids
• Propylene glycol
• Isoniazid
• Lactic acid
• Ethylene glycol
• Salicylates

Question 6

Activated charcoal does not bind ____________.

Answer 6

metals, alcohol, or hydrocarbons

Question 7

The lethal dose of acetaminophen is ______________.

Answer 7

150 mg/kg; so 7,500 mg for a 50 kg person and 15,000 mg for a 100 kg person

Question 8

Be sure to get drug levels in patients with _______________ overdose.

Answer 8

acetaminophen

Question 9

Unlike with acetaminophen poisoning, patients with aspirin toxicity are usually _______________.

Answer 9

quite ill appearing; aspirin uncouples oxidative phosphorylation, so at high doses lactic acidosis results

Question 10

Patients who have ingested ______________ will often have crystals in their urine that show up under a Woods lamp.

Answer 10

ethylene glycol

Question 11

The first-line treatment of methanol or ethylene glycol poisoning is ________________.

Answer 11

fomepizole (alcohol dehydrogenase inhibitor that prevents the accumulation of toxic aldehydes)

Question 12

Like with all patients in the emergency room, those with suspected toxidromes should first be ______________.

Answer 12

evaluated using the primary survey (ABCDE)

Question 13

What substances are screened in serum?

Answer 13

• Acetaminophen
• Aspirin
• Ethanol

Question 14

What non-serum test can you do in suspected toxic exposures?

Answer 14

ECGs (e.g., in TCA overdose)

Question 15

Explain how activated charcoal can be harmful.

Answer 15

Aspiration can lead to chemical pneumonitis.

Question 16

Where is scopolamine found?

Answer 16

Seeds of a South American plant (used to drug people)

Question 17

What are ways to distinguish between anticholinergic and sympathomimetic overdoses?

Answer 17

• Sweating is found in sympathomimetics, whereas anticholinergic drugs cause dryness.
• Hypertension is much higher in sympathomimetics.
• Both cause AMS, but sympathomimetics cause agitation while anticholinergics cause grabbing at invisible objects.

Question 18

A lot of drugs can cause serotonin syndrome: _________________.

Answer 18

• MAOI
• Cocaine
• Dextromethorphan
• SSRIs/SNRIs
• Fentanyl

Question 19

Serotonin syndrome can mimic sympathomimetic overdose. What is a good way to distinguish the two?

Answer 19

Serotonin syndrome causes stiffness/myoclonus.

Question 20

Benzodiazepine overdose and opiate overdoses can be very similar. How can you distinguish the two?

Answer 20

Opiates cause prominent bradypnea and pupil constriction.

Question 21

True or false: opiate withdrawal can cause seizures.

Answer 21

False. This is part of why naloxone is considered so safe and is in police cars.

Question 22

Why do you need to be careful giving flumazenil in a patient with suspected benzodiazepine overdose?

Answer 22

Benzodiazepine withdrawal can cause seizures. Benzodiazepines are also used to treat seizures, but if you’ve given flumazenil then they won’t work.

One of the main uses is in cases when too much benzodiazepines are given in procedural sedation.

Question 23

ACLS doses of atropine are roughly ___________, while doses used to treat organophosphate toxicity are _____________.

Answer 23

0.5 mg; 6 mg to 12 mg

Question 24

What is the big take home of the Rumack nomogram?

Answer 24

• Less than 4 hours since ingestion, the nomogram is unreliable.
• Greater than 24 hours since ingestion, levels will likely be undetectable.