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EM > Poisonings > Flashcards

Poisonings Flashcards

1
Q

As you’re walking toward the room of a suspected poisoning, what actions should you take upon arriving? (3)

A
  • Assess the primary survey
  • Order an EKG
  • Order a safety companion or standard suicide precautions
  1. Hypoxia: Place on 100% O2 nonrebreather (also useful prior to intubation)
  2. Hypoglycemia: obtain a point of care fingerstick blood glucose
  3. Opioids: administer Narcan 0.4 to 2mg IV to reverse opiates
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2
Q

Coma cocktail, per wiki:

A

A standard combination included:

  • dextrose (1 Amp D50W IV),
  • flumazenil (0.2 mg IV),
  • naloxone (2 mg IV), and
  • thiamine (100 mg IV).

It has been suggested that the use of naloxone and flumazenil be administered more selectively than glucose and thiamine.

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3
Q

What are some key historical questions to ask in a poison pt?

A

What?
How much?
When?
Why? (accidental or intentional)?

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4
Q

What are important PE things to pay attn to during the exam of a poison pt?

A
  • Vital Signs (there is a reason they are called “vital signs”)
  • Mental status (agitated, confused, somnolent?)
  • Pupils
  • Skin color
  • Track marks/skin poppers
  • Presence of sweat
  • Bladder size (urinary retention)
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5
Q

Describe the classic anticholinergic toxidrome.

A
  • Mad as a hatter (Altered mental status)
  • Blind as a bat (mydriasis)
  • Hot as Hades
  • Red as a beat
  • Dry as a bone
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6
Q

List some eg’s of meds that can cause anticholinergic toxidrome

A
  • TCA’s Tricyclic antidepressants
  • Antihistamines
  • Overactive bladder medication
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7
Q

Describe the classic cholinergic toxidrome.

A

DUMBBELS

Diarrhea
Urination
Miosis/Muscle weakness.
Bronchorrhea/Broncbhospasm
Bradycardia
Emesis
Lacrimation
Lethargy
Salivation/Sweating
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8
Q

*What are common causes of cholinergic toxidrome?

A

organophosphate poisoning (pesticides) and nerve agents

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9
Q

*Tx of cholinergic toxidrome?

A

Atropine, pralidoxime, decontaminate

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10
Q

Tx of anticholinergic toxidome?

A

Mostly supportive (except TCA–separate)

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11
Q

Describe the classic the classic sympathomimetic syndrome.

A 
Tachycardia
Hypertension
Mydriasis
Diaphoresis
Hyperthermia
Agitation
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12
Q

List some drugs that can cause sympathomimetic syndrome.

A

over-the-counter cold agents (containing ephedrine), illegal street drugs (eg, cocaine, amphetamines, methamphetamine), dietary supplements (ephedra), and illicit designer drugs (eg, 3,4-methylenedioxy methamphetamine (MDMA, “ecstasy”)

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13
Q

Tx of sympathomimetic syndrome?

A

Involves sedation, hydration, and treatment of complications such as rhabdomyolysis and hyperthermia.

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14
Q

Classic signs of opioid OD?

Tx?

A

Apnea
Hypoxia
Unresponsiveness
Flash pulmonary edema (rare)

Naloxone

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15
Q

What are some important tests to perform in the toxicology pt?

A
  • EKG
  • Tox screen
  • Tylneol/ASA testing
  • Lytes
  • Levels of specific med
  • Other (depends)
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16
Q

*What are the causes of AG-metabolic acidosis?

A 
MUDPILES
M = Methanol
U = Uremia
D = DKA or AKA
P = Paraldehyde
I = Iron, Isoniazid
L = Lactate (many causes including carbon monoxide, sepsis, blood loss?)
E = Ethylene Glycol
S = Salicylates
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17
Q

List some common decontamination methods in poisoning,

A

Activated Charcoal
Whole Bowel Irrigation
Gastric Lavage (rare)

18
Q

How does activated charcoal work?

When is it most efficacious (time)?

*What does charcoal NOT bind?

A

Activated Charcoal is given orally to absorb toxins that are present in the GI tract. Toxins bind to the charcoal and are excreted without being digested.

It is most efficacious if given within the first hour post ingestion but still works beyond that point.

Charcoal does not bind metals (such as iron), alcohols or hydrocarbons. It should be avoided in patients with somnolence as they run the risk of aspiration

19
Q

What is whole bowel irrigation?

When is it used?

A

Whole bowel irrigation involves the administration of an osmotically balanced polyethylene glycol electrolyte solution (like Go Lytely) to flush the bowel to prevent the absorption of ingested toxins.

It is used in cases where charcoal is not effective, with certain sustained release products, and in cases of illicit drug packet ingestions (body packers).

20
Q

What is gastric lavage, and when might it be used?

A

Lavage involves the application of a very large bore (36 – 40 French) orogastric tube and then flushing the stomach with aliquots of water ideally to obtain pill fragments.

Gastric Lavage is rarely used and carries significant risks with questionable benefit. In some cases, however, such as recently ingest lethal substances or an intubated overdose following recent ingestion, the benefits may outway the risks and warrant use.

21
Q

What old method of decontamination is no longer recommended?

A

(syrup of) ipecac

- induces forceful vomiting

22
Q

How long should poison pts be observed, typically, after their sx are alleviated?

A

Many patients with potential ingestions may be observed for six hours and then dispositioned (home or psychiatric treatment facility) if clinically asymptomatic (provided the ingestion is not an extended release agent).

23
Q

The lethal dose of acetaminophen (APAP) is ____mg/kg.

24
Q

Describe the pathophysiological mechanism behind acetaminophen tox.

A

In an acute overdose, APAP is metabolized to NAPQI which combines with glutathione and is excreted. When the majority of the glutathione is used, NAPQI causes hepatic toxicity.

25
Q

*Describe what do give in acetaminophen OD.

A

In addition to decontamination with repeated doses of activated charcoal, the antidote N-acetylcysteine (Mucomyst) should be administered if indicated by the nomogram.

26
Q

What are the typical sx in the 1st 2 stages of acetaminophen OD?

27
Q

Describe the appearance of someone with an ASA OD.

A

usually quite ill appearing, breathing fast, vomiting, confused, and sometimes febrile.

28
Q

In general, what is the cause, pathophysiologically (cellularly), of ASA poisoning?

A

The toxic effects are complex and involve an uncoupling of oxidative phosphorylation –> profound AG-metabolic acidosis

29
Q

*The general approach to aspirin overdose is:

A
  • Management of the airway,
  • gastric decontamination,
  • the administration of sodium bicarbonate,
  • hemodialysis.
30
Q

List the receptors that TCAs affect and how.

A
  1. Anticholinergic
  2. Direct alpha-adrenergic blockade
  3. NE and 5-HT re-uptake inhibition
  4. Blockade of fast sodium channels in myocardial cells
31
Q

List some of the worrisome symptoms/signs of TCA OD

A
  • tachycardia
  • prolongation of the QRS complex
  • dysrhythmias
  • cardiovascular collapse
  • protracted seizures
32
Q

Treatment of TCA overdose includes close monitoring for a period of at least 6-8 hours in the asymptomatic patient. In the setting of QRS widening, ____________________ should be administered.

A

Sodium bicarbonate

33
Q

While any alcohol consumed in great quantities can be dangerous, there are three major alcohols that are considered “toxic”. These “toxic” alcohols include ______________, _______________, and ______________.

A
  • isopropanol
  • methanol
  • ethylene glycol
34
Q

Where is isopropyl alcohol typically found?

A

Many solvents, mouthwashes, and rubbing alcohols

35
Q

What are methanol and ethylene glycol typically used for?

A

Fuel, solvent, and antifreeze in pipelines and windshield washer fluid (esp. ethylene glycol), coolants

36
Q

Which of the following will NOT cause an AG-metabolic acidosis:

  • isopropanol
  • methanol
  • ethylene glycol
A

Isopropanol

37
Q

Under what substance ingestion should you apply wood’s lamp to the urine to look for fluorescence?

A

Ethylene glycol

  • The urine can also be examined for the presence of calcium oxalate crystals.
38
Q

Which of the following ingestions is NOT life threatening and can be managed with supportive care?

  • isopropanol
  • methanol
  • ethylene glycol
A

Isopropanol

- In rare instances, hemodialysis may be required

39
Q

*Methanol is metabolized to formaldehyde, and ethylene glycol is broken down into oxalate. All alcohols are metabolized by alcohol dehydrogenase (ADH). Therefore, the initial treatment for methanol and ethylene glycol involves the blockade of ADH. This can be accomplished by either ____________ or ___________.

A

simple ethanol or fomepizole

  • In addition, removal of the toxin may be necessary by hemodialysis. Sodium bicarbonate and glucose may also be necessary.
40
Q

Even after 6 hours of observation after they have stabilized, what is the danger of discharging poison pts?

A

May still be danger to themselves.

41
Q

What route of medication or agent administration should you avoid in somnolent pts?

A

PO

- Risk of aspiration

42
Q

True or false:
Aggressive alkalinization and/or antidotal therapy with fomepizole or ethanol are NOT indicated in isolated isopropyl alcohol ingestions.

A

True

- Supportive care only

EM (13 decks)

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