Section 6: Drugs Flashcards

Question 1

Q

6.1 Given an exposure, identify a drug that when ingested in small amounts is potentially life
threatening.

Answer

A

6.1 Given an exposure, identify a drug that when ingested in small amounts is potentially life
threatening.

Question 2

Q

Cyclic antidepressants (amitriptyline; imipramine; desipramine; nortriptyline; doxepin)

Answer

A

a. Of note, imipramine is used for childhood enuresis. Comes in 150mg tabs. One tab for a 10kg toddler can be fatal.
b. amoxapine has less cardiotoicity but sz and coma are frequent presenting signs

Question 3

Q

Phenothiazines (chlorpromazine; thioridazine; thorazine)

Answer

A

a. anticholinergic, CNS effects, quinidine like cardiotoxicity, rigidity

Question 4

Q

Beta blockers (metoprolol; propranolol)

Answer

A

a. bradycardia/hypotension generally well tolerated in peds
b. *hypoglycemic coma and sz in peds
c. Propranolol - may cause sz and altered cardiac conductivity
d. Sotalol - may cause QT prolongation/torsades

Question 5

Q

Calcium channel blockers (amlodipine; diltiazem; nicardipine; nifedipine, verapamil)

Answer

A

a. bradycardia and hypotension

b. cardiovascular collapse and sz (verapamil)

Question 6

Q

Quinidine (antimalarial medication)

Answer

A

a. type 1a antiarrhythmic

b. cardiac rhythm disturbances

Question 7

Q

Clonidine

Answer

A

a. coma, miosis, bradycardia, hypotension in children

b. patches have caused critical cardiovascular depression.

Question 8

Q

Imidazoline eye drops

Answer

A

a. Similar to clonidine. SA node arrest

Question 9

Q

Lomotil (combination formula - diphenoxylate and atropine)

Answer

A

a. Diphenoxylate is an opiod. 2 tabs have been fatal. Can have confusing constellation with anticholinergic component, but coma and respiratory depression are most common

Question 10

Q

Methadone

Answer

A

a. CNS and respiratory depression

* QTc prolongation*

Question 11

Q

Topicals

Answer

A

a. Benzocaine
i. Methemoglobinemia (cyanosis)
ii. Sz (common with local anesthetics but uncommon with benzocaine)

b. Camphor
i. CNS, resp depression, sz (usually within an hour)

c. Lindane
i. Organochlorine (chlorinated hydrocarbon)
- topical scabicide
- Sz and CNS depression when ingested
(permethrin - less toxic alternative)

d. Methyl salicylate
i. ASA toxicity

Question 12

Q

Chloroquine

Answer

A

a. Cardiac dysfunction

1 tab/300g - fatal to a 1 y/o

Question 13

Q

Phenylpropanolamine (amphetamine)

Answer

A

a. Common ingredient in OTC decongestants. Narrow therapeutic-toxic margin
b. B-agonist action
c. HTN with compensatory bradycardia
d. Cerebral infarction noted in adults
e. SVT in infant

Question 14

Q

Quinine

Answer

A

a. Used to treat malaria and nocturnal muscle cramps
b. Similar to quinidine but less cardiotoxic
c. Causes direct retinal toxicity
d. Hypersensitivity reactions:
i. Blackwater fever (hemolysis, hemoglobinemia, renal failure)

Question 15

Q

Sulfonylureas

Answer

A

a. Ex glyburide; glipizide; chlorpropamide

b. Hypoglycemia: can be delayed and persistent

Question 16

Q

Theophylline

Answer

A

a. Used to treat asthma, COPD, apnea of prematurity

b. Sz, cardiac arrhythmias
c. Action:
i. Beta 1 and 2 stimulation
ii. Increase heart rate/contractility; bronchodilation; skeletal muscle vasodilation; uterine relaxation
iii. Inhibition of phosphodiesterase and adenosine receptors
iv. Refractory sz with decreased cerebral blood flow in OD

d. Narrow therapeutic window; Toxicity at 80-100mg/kg blood level
e. Chronic toxicity more dangerous than acute
f. Usually sustained release
g. Should draw levels Q2-4 hrs as levels can peak 12-16 hrs post ingestion
h. Caffeine OD has similar s/s and can create false positive on old blood tests

Question 17

Q

i. S/S of Theophylline

Answer

A

i. Mild
1. GI: n/v
2. CNS: anxiety; tremor
3. Labs: Metabolic acidosis; electrolyte abnormalities

ii. Severe
1. GI: vomiting
2. Cardiac: hypotension, dysrhythmias
3. CNS: seizures (often refractory)
4. Labs: metabolic acidosis

iii. Chronic
1. Vomiting occasionally
2. Tachycardia common
3. Hypotension rare

j. Metabolic effects (hypokalemia and hyperglycemia) do occur
k. Seizures with low blood levels

Question 18

Q

l. Labs (Theophylline):

Answer

A

i. LOW: potassium, phosphorus; magnesium

ii. HIGH: calcium, glucose

Question 19

Q

m. Treatment (Theophylline)

Answer

A

i. Supportive
ii. Consider nonselective beta blockers for tachycardia and hypotension (propranolol or esmolol)
iii. Caution for hx of asthma/wheezing
iv. Consider multi-dose activated charcoal (enteroenteric recirculation)
v. Dialysis for severe toxicity (status or level > 200mg/L)

Also consider iron, antidepressants, other cardiovascular drugs, salicylates, anticonvulsants.

Question 20

Q

6.2 Identify the toxicity and symptoms of exposure to analgesics including over-the-counter or
prescription.

Answer

A

Analgesics, Antipyretics, and Anti-inflammatory agents:

Question 21

Q

Acetaminophen

Answer

A

a. Normal max dose
i. 75mg/kg/day or 4g/day for a normal adult

b. Single acute ingestion toxic dose
i. Adult local referral 140 mg/kg local - national is >200mg/kg or 10g, whichever is less.
ii. Child 200mg/kg

c. High risk pts
i. Chronic alcoholics (will have more P450 thus create more NAPQI)
ii. Malnutrition (have less substrate to bind NAPQI thus creates more liver damage)
iii. Pregnant patients (fetal death)
iv. Pts taking CYP2E1/cytochrome P-450 inducers (isoniazid)
[1. This is principal enzyme responsible for breaking acetaminophen into toxic metabolites (thus inducers worsen hepatic injury)]
v. Kids < 5 y/o use sulfation pathway more; so they have less NAPQI production

Question 22

Q

d. S/S of OD (Acetaminophen)

Answer

A

Stage 1; (0-24hrs)
1. Anorexia, n/v

Stage 2; (24-72hrs)
1. Elevated AST/ALT (AST greater); bilirubin and PT; n/v resolve

Stage 3; (72-96hrs)
1. Hepatic necrosis with increasing AST/ALT; coagulopathy; jaundice; hepatic and renal failure; encephalopathy; death or stage 4

Stage 4; (>96hrs)
1. Healing of liver damage with resolution of enzymatic and metabolic abnormalities

Question 23

Q

e. Labs (Acetaminophen)

Answer

A

i. APAP 4 hrs post ingestion (for extended release check 4+6 hour levels)
ii. BUN/Cr
iii. AST/ALT
iv. PT/INR
v. Glucose

Question 24

Q

f. Four hr treatment level on Rumack/Matthew Nomogram

Answer

A

i. Treatment level is 150 mcg/ml
ii. Excludes chronic ingestion
iii. Excludes extended release, diphenhydramine containing, or anticholinergic products
iv. In these cases with elevated LFTs (AST usually > than ALT) start NAC with any positive APAP level

Question 25

Q

g. Treatment (Acetaminophen)

Answer

A

i. Activated Charcoal (<1-2 hrs)
ii. NAC (best started w/i 8 hrs)
iii. Anti-emetics (Zofran preferred)

NOTE: large OD can act as a metabolic poison and cause anion gap metabolic acidosis.

i. Dialysis is effective, but rarely used. May be consideration in later term pregnancy or with significant acidosis in massive ingestion.

Question 26

Q

Kings College Criteria

Answer

A

Ph < 7.3 or

INR >6.5, Cr > 3.4, and grade 3-4 encephalopathy

Question 27

Q

Aspirin

Answer

A

a. Analgesia, anti-inflammatory, antipyretic
iii. Common forms ASA: Oil of Wintergreen (ACF - 1.39/Sp.G - 1.18), Bismuth salicylate (ACF - 0.49)
b. Delayed absorption in OD (bezoar formation)
c. Is an UNcoupler

Question 28

Q

d. S/S (Aspirin)

Answer

A

i. Respiratory alkalosis (protective as alkalotic environment prevents crossing into CNS)
ii. Possible metabolic alkalosis from emesis
iii. Final Metabolic acidosis from mitochondrial uncoupling
iv. GI upset, tinnitus/auditory changes, tachypnea followed by
v. Coma, seizures, hyperthermia, muscle rigidity
vi. Chronic OD more toxic

Question 29

Q

e. Treatment (Aspirin)

Answer

A

i. Bicarb for acidosis (Goal pH 7.5) and/or ASA > 40mg/dL (national ASA > 30 and rising)

ii. Dialysis for severe OD (level >100 mg/dL, coma, seizures).
1. dialysis for inability to tolerate fluids/bicarb treatment (renal failure or pulmonary edema)

iii. Monitor ASA; BMP level Q2H

iv. May need glucose with ASA associated AMS
1. Decreased BS in brain even when BS is normal in blood

v. Standard hydration changing to LR
1. NS could create some anion gap acidosis and increase distribution across blood/brain barrier

Question 30

Q

Colchicine

Answer

A

a. General cellular poison, inhibits dividing cells, rapidly absorbed, extensively distributed to body tissues

b. Multiorgan effects can occur from days to weeks
i. s/s delayed 2-12 hrs in acute OD
ii. severe gastritis: abd pain, n/v/bloody diarrhea
iii. shock, sz, coma, lactic acidosis
iv. rhabdo, kidney failure, DIC
v. Late: bone marrow suppression, alopecia, myopathy, neuropathy

c. Renal insufficiency, erythromycin, cimetidine and cyclosporine inhibit colchicine clearance
d. Treatment: supportive care, AC, dialysis not effective

Question 31

Q

Nonsteroidal anti-inflammatory drugs

Answer

A

a. Act by prostaglandin inhibition (COX inhibitors); inflammatory mediators

b. Five kinds of NSAIDS
i. Propionic acids (ibuprofen)
ii. Acetic acids (toradol)
iii. Fenamic acid (can cause seizures; requires aggressive management)
[1. Ex mefenamic acid/Ponstel]
iv. Oxicams (piroxicam)
v. Pyrazolines (require aggressive management)

Question 32

Q

c. S/S (Nonsteroidal anti-inflammatory drugs)

Answer

A

i. GI c/o
ii. Mild CNS disturbances (drowsiness, h/a)
iii. Massive OD
1. Sz, hypotension, metabolic acidosis, renal and hepatic dysfunction
iv. S/S may occur in children after OD >100mg/kg

Question 33

Q

d. Treatment (Nonsteroidal anti-inflammatory drugs)

Answer

A

i. Symptomatic
ii. Charcoal
iii. Dialysis not useful

Question 34

Q

Opioids

Answer

A

a. Slang terms: China white, brown, superbuick, black tar, hot shot, bird’s eye, homicide
b. Use: snorted, smoked, injected, oral
c. Three receptors: Delta, Kappa, Mu
d. S/S
i. CNS and respiratory depression
ii. Miosis
iii. Noncardiogenic pulmonary edema (complication)

Question 35

Q

e. Atypical Opioids

Answer

A

i. Have serotonergic properties:
1. Meperidine

ii. Do not cause miosis/may cause seizures:
1. Meperidine/Demerol (sz from metabolite which accumulates with renal
insufficiency as well as from serotonergic effect)
2. Propoxyphene/Darvon (sz)
3. Tramadol (sz)

Question 36

Q

f. Treatment (opioids)

Answer

A

i. Supportive
ii. Narcan
1. Monitor 4-6 hrs s/p last dose of narcan. Increase time with renal insufficiency as narcan is renally eliminated.

Question 37

Q

g. Withdrawal (opioids)

Answer

A

i. CNS excitation (restless)
ii. GI (n/v/d/abd pain)
iii. Piloerection, lacrimation, rhinorrhea, diaphoresis
iv. ***FEVER and AMS are not associated with opioid withdrawal

Question 38

Q

h. Meds for opioid withdrawal (Methadone, Clonidine, Buprenorphine)

Answer

A

i. Methadone (causes QT prolongation)
ii. Clonidine (causes sleepiness/HTN followed by apnea, coma, bradycardia, hypotension)
iii. Buprenorphine (Suboxone). Has opioid antagonist and agonist in the same medication. Can trigger a mild withdrawal in an opioid using patient.

Question 39

Q

Serotonin receptor agonists (i.e. sumatriptan)

Answer

A

a. In therapeutic use cause cerebral vasoconstriction, theoretically antagonizing cerebral vasodilation that causes migraines.
b. In overdose lose cerebral selectivity and cause excessive vasoconstriction. This causes HTN and end organ ischemia. Can cause serotonin syndrome.
c. Treatment: supportive care. Treat HTN with nitroprusside or nitroglycerin. Labetalol and dihydropyridine calcium channel blockers may be effective.
d. AC okay. Hemodialysis not effective

Question 40

Q

Tramadol

Answer

A

a. Opioid analgesic, also inhibits norepi and serotonin reuptake

S/S:
Euphoria, CNS depression, n/v, serotonergic, sz, no miosis

Treatment:
i. Narcan, charcoal with caution d/t CNS depression, hemodialysis not effective

Question 41

Q

6.3 Identify the toxicity and symptoms of exposure to anticonvulsants.

Answer

A

6.3 Identify the toxicity and symptoms of exposure to anticonvulsants.

Question 42

Q

General s/s of anticonvulsant OD

Answer

A

a. AMS (anxiety, confusion, irritability, lethargy, somnolence)
b. Ataxia
c. N/V
d. Coma, resp depression, hypotension (LARGE OD)
Anticonvulsant Hypersensitivity Syndrome
i. Seen with drugs with an aromatic amine or sulfonamides (Phenobarbital, Primidone)
ii. S/S:
- Skin eruption (SJS); eosinophilia, hepatitis, interstitial nephritis, hypothyroid

Question 43

Q

Carbamazepine/Oxcarbazepine (Tegratol/Trileptal)

Answer

A

a. Nystagmus, ataxia, hyperreflexia, CNS depression, dystonia, mild anticholinergic s/s

b. Can progress to coma, seizures, rhabdo, renal failure, cardiac interval changes
i. Sz potential close to therapeutic dose
ii. hyponatremia (trileptal)

c. AHS (anticonvulsant hypersensitivity syndrome)

Question 44

Q

Lamotrigine (Lamictal)

Answer

A

a. Sz, Rash (SJS), AHS (anticonvulsant hypersensitivity syndrome)
b. CNS depression, dizziness, ataxia, nystagmus, hypertonia, QRS prolongation, n/v, hypokalemia, fever, hepatitis, renal failure

Question 45

Q

Levetiracetam (Keppra)

Answer

A

a. drowsiness

Question 46

Q

Gabapentin

Answer

A

a. Somnolence, ataxia, dizziness, mild tremor, slurred speech, diplopia

Question 47

Q

Phenytoin (Dilantin)

Answer

A

a. Rash (DRESS), IV formulation causes cardiotoxicity, AHS (anticonvulsant hypersensitivity syndrome)
b. IV use: bradycardia, hypotension, dysrhythmias. Cardiotoxicity believed from diluent propylene glycol/Na channel blockade
c. Oral: n/v, *NYSTAGMUS, ataxia, CNS depression
d. Chronic use risk of DRESS (resembles viral infection with multiorgan/system involvement)

Question 48

Q

Pregabalin (Lyrica)

Answer

A

a. Limited data. Large ingestions minimal symptoms. CNS depression to coma.

Question 49

Q

Tiagabine

Answer

A

a. Somnolence, confusion, agitation, dizziness, ataxia, tremor, clonus, sz

Question 50

Q

Topiramate (Topamax)

Answer

A

a. Sz, non AG acidosis, hyperkalemia

b. Sedation, confusion, slurred speech, ataxia, tremor, anxiety, sz

Question 51

Q

Valproic Acid (Depakote)

Answer

A

a. Hyperammonemia, cerebral edema
b. CNS depression, emesis, tachycardia, QTc prolongation, resp depression, sz, cerebral edema, hyperammonemia, high sodium, low calcium

Question 52

Q

Zonisamide

Answer

A

a. Na channel blockade. Somnolence, ataxia, agitation, bradycardia, hypotension, resp depression, sz

Question 53

Q

6.4 Identify the toxicity and symptoms of exposure to non-cyclic antidepressants.

Answer

A

General s/s expected to cause ataxia, sedation, coma. Noncyclic or tetracyclic antidepressants less toxic than tricyclic or MAOIs.

Question 54

Q

Bupropion (Wellbutrin)

Answer

A

a. Stimulant that can cause sz. Acts more like amphetamine than serotonergic
b. Tachycardia and mild HTN, agitation/lethargy, hallucinations, sz, tremors, clonus, hyperreflexia
c. In larger ingestions may see status, hyperthermia, hypotension, coma, cardiac interval prolongation.
d. *increased sz risk for 24 hrs with >600mg of ER product

UDS false + for amphetamines
sometimes prescribed for smoking cessation

Question 55

Q

Desvenlafaxine/Venlafaxine (SNRI)

Answer

A

a. Serotonergic effects in mild toxicity
b. Serotonin syndrome, QRS and QT prolongation. Rhabdo. Sz.
c. Somnolence in mild toxicity progressing to delirium in more severe toxicity
d. Exacerbation of CHF

Question 56

Q

Duloxetine (Cymbalta) - (SNRI)

Answer

A

a. OD rare.
b. Mild to moderate: sleepy, GI upset, tachy, diaphoresis, agitation, confusion, HTN
c. Severe toxicity: serotonin syndrome, sz, hypotension, coma

Question 57

Q

Escitalopram (Lexapro) - (SSRI)

Answer

A

a. Serotonergic s/s mild to severe. Citalopram causes delayed QT prolongation. Sz

Question 58

Q

Lithium

Answer

A

Acute or Chronic (chronic worse)

S/S OD ACUTE

i. n/v
ii. delayed neuro effects

S/S OD CHRONIC

i. Tremor, confusion, ataxia, slurred speech, myoclonus, hyperreflexia
ii. **severe** agitated delirium, coma, hyperthermia, convulsions, cerebellar effects, Parkinson like, Diabetes Insipidus

ECG changes

i. T wave flattening
ii. Prolonged QT

Labs

i. Obtain serial blood levels Q2H 1. Lithium and BMP
ii. Goal Na+ 145-150 for max renal lithium excretion

Question 59

Q

f. Treatment (Lithium)

Answer

A

i. NO ACTIVATED CHARCOAL
ii. IVF (watch for hypernatremia)
iii. Dialysis for severe cases (Sz or AMS)

Interactions
i. Lithium with SSRIs can precipitate serotonin syndrome

Question 60

Q

Monoamine Oxidase Inhibitors

Answer

A

a. Mechanism of action
i. Makes dopamine, norepi and serotonin more available

b. Food interactions
i. Tyramine containing products (beer, fava beans, aged cheese, aged meats, pickled foods, red wine, yeast extract and pepperoni)
ii. MAO-A found in the liver and intestinal wall; metabolizes tyramine (tyramine releases catecholamines from neurons)

Question 61

Q

MAOI Types

Answer

A

c. 1 st generation Ex: Marplan, Nardil, Parnate are nonselective for MAO-A/MAO-B

d. Newer MAOI have selectivity for MAO-B)
i. Ex selegiline will not interact with foods
ii. Note: selectivity is lost in overdose
iii. Metabolized to amphetamines: causes + amphetamine on UDS

e. Other products with MAO effect: linezolid (abx for MRSA), PMA (mistaken for MDMA), St John’s Wort

Question 62

Q

f. Associated syndromes (MAOI)

Answer

A

i. Sympathomimetic syndrome
1. When MAOIs used with amphetamines, cocaine, phentermine, PCP

ii. Serotonin syndrome
1. Can result from MAOI use with other serotonergic meds [SSRIs, LSD, dextromethorphan, meperidine, and tramadol]

iii. Use with foods high in tyramine can cause hyperthermic/hypertensive crisis

Question 63

Q

g. S/S of OD (MAOI):

Answer

A

i. Tachycardia, HTN, flushing, headache in mild toxicity
ii. Hyperadrenergic, hypertensive crisis in severe toxicity (hypertension, hyperthermia, delirium, seizures, cardiovascular collapse, multi-organ failure)

Question 64

Q

h. Treatment (MAOI)

Answer

A

i. Supportive care
ii. Short acting anti-hypertensives (NO BETA BLOCKERS)
iii. Benzos for seizures
iv. Cyproheptadine for oral serotonergic antidote

Answer 65

A

a. Ex fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine, venlafaxine (Effexor), trazodone (Desyrel)
b. May interact with one another or MAOIs to produce serotonin syndrome (The classic clinical triad is altered mental status, neuromuscular abnormalities (tremors, clonus, hyperreflexia, rigidity), and autonomic instability (eg, hypertension, tachycardia, hyperthermia). Mydriasis

Answer 66

A

a. Peripheral alpha-adrenergic blockade causing hypotension (and orthostatic hypotension) w/ reflex tachycardia. May see bradycardia
b. Serotonin syndrome, CNS depression, sz, QT prolongation, priapism, tremors, clonus, hyperreflexia

Answer 67

A

6.5 Identify the toxicity and symptoms of exposure to tricyclic antidepressants.
Amitriptyline.
Amoxapine.
Desipramine (Norpramin)
Doxepin.
Imipramine (Tofranil)
Nortriptyline

Answer 68

A

a. s/s generally appear within 1 hr but may be delayed if mixed ingestion or delayed gastric emptying
b. initial s/s are often anticholinergic (dry mouth, blurred vision, urinary retention, dizziness, n/v)

Answer 69

A

i. Tachycardia
1. Biogenic amine reuptake inhibitor (serotonin and norepi) causes initial hypertension/tachycardia

ii. Initial hypertension then hypotension

iii. QRS prolongation (Na channel blockade)
1. Treat with Bicarb
2. 50 mEq IVP. If QRS narrows, assume drug related and start drip
3. Drip = 3 amps bicarb in 1L D5W w/ 40meq KCl
4. Rate = 2cc/kg/hr or 2x maintenance

iv. QTc prolongation (K channel blockade)
1. Treat with 2g Mag Q6H

*Note: do not use procainamide or other type 1a or 1c antiarrhythmic agents for vtach as may aggravate cardiotoxicity

Answer 70

A

i. Seizures
1. From GABA inhibition or antihistamine effect
2. Treat with Benzos

ii. CNS depression & coma
1. resembles brain death. May last 3-4 d
2. Do not withdraw care

Answer 71

A

i. Alpha blockade causes vasodilation
Treat with
    1. IVF
    2. norepi (alpha 1&amp;2 agonist)
    3. phenylephrine (alpha 1 agonist)

**no dopamine (beta agonist) as it relies on body’s release of catecholamines which may be depleted

Answer 72

A

6.6 Identify the toxicity and symptoms of exposure to antimicrobials and antimalarials.

Answer 73

A

a. Some IV preparations may contain preservatives such as benzyl alcohol or large amounts of potassium or sodium.

b. Quinolones (ciprofloxacin/Cipro;
levofloxacin/Levaquin) and macrolides (azithromycin and erythromycin) cause prolonged QT/torsades.

c. Sulfonamides can cause sulfhemoglobenemia.
d. Linazolid (Zyvox) is MAOI and serotonergic.

Answer 74

A

a. Toxicity more closely associated with trough levels of drug.
b. Renal damage (acute tubular necrosis), ototoxicity (irreversible), and vestibular toxicity (irreversible).
i. Renal injury may go unnoticed until significant.
c. Crosses placenta and some may cause fetal ototoxicity.

Examples:
gentamicin, amikacin, tobramycin, neomycin, and streptomycin

Answer 75

A

a. Expect GI upset in oral ingestion
b. Sz have occurred after parenternal OD
c. Ceftriaxone has caused pseudoithiasis (gall bladder sludge) when administered rapidly
d. Some have caused coagulopathy

Examples:
    Ancef and Kefazol (cefazolin)
    Ceclor and Cefaclor (cefaclor)
    Cefdinir.
    Ceftin and Zinacef (cefuroxime)
    Duricef (cefadroxil)
    Keflex and Keftabs (cephalexin)
    Maxipime (cefepime)
    Rocephin (ceftriaxone)

Answer 76

A

Treatment of malaria, parasitic diseases, lupus, and rheumatoid arthritis

Examples:
Chloroquine (more potent), hydroxychloroquine/ Plaquenil, Primaquine

 ii. Mild to moderate ingestion may see GI upset, dizziness, headache, visual disturbances (can cause blindness), and auditory disturbances (can cause deafness) .    iii. Severe ingestion may see coma, sz, shock, cardiac interval changes, respiratory and cardiac arrest.

Extremely long half life
1. Primaquine causes GI upset and may cause methemoblobinemia & hemolysis.

Findings of gastritis, visual disturbances and neuromuscular excitability especially if accompanied by hypotension, QRS /QT prolongation, or ventricular
arrhythmias, should suggest chloroquine.

Answer 77

A

a. Cipro associated with crysatalluria. Inhibits cytochrome P450 1A2, GI upset
* Severe SE: tendon ruptures, extreme fatigue, joint and muscle pains, nerve pains, nervous system disturbances

Examples:
ciprofloxacin (Cipro), gemifloxacin (Factive), levofloxacin (Levaquin), moxifloxacin (Avelox), norfloxacin (Noroxin), and ofloxacin (Floxin)

Answer 78

A

Seizures, metabolic acidosis

Answer 79

A

MAOI, serotonergic, thrombocytopenia, anemia, peripheral neuropathy.

*Give pyridoxine for seizures

Examples:
linezolid (Zyvox), tedizolid (Sivextro)

Answer 80

A

a. Seizures in pts with renal dysfunction, kidney problems, leukopenia, neutropenia, bleeding disorder, hypokalemia. Risk of toxicity higher in pts with renal insufficiency

Answer 81

A

Can cause Antabuse (disulfiram) type reactions

*When ingested with alcohol. The disulfiram reaction is a very uncomfortable reaction characterized by severe flushing, and may be accompanied by tachycardia and hypotension.

Answer 82

A

6.7 Identify the toxicity and symptoms of exposure to antipsychotic agents (neuroleptics).

aripiprazole (Abilify)
asenapine (Saphris)
cariprazine (Vraylar)
clozapine (Clozaril)
lurasidone (Latuda)
olanzapine (Zyprexa)
quetiapine (Seroquel)
risperidone (Risperdal)

Answer 83

A

a. Anticholinergic
i. tachycardia, dry mouth, dry skin, urinary retention

b. CNS depression/sedation

c. Alpha-adrenergic blockers
i. hypotension and miosis

d. QT prolongation (occasional QRS prolongation)

e. Extrapyramidal symptoms
i. torticollis, jaw muscle spasm, oculogyric crisis, rigidity, bradykinesia, pill rolling tremor
ii. Often caused by dopamine receptor blockade.

f. Disturbed temperature regulation
i. hypo or hyperthermia

g. Neuroleptic malignant syndrome
i. Rigidity, hyperthermia, sweating, lactic acidosis, rhabdomyolysis

Dystonias in children should always suggest the possibility of antipsychotic exposure

Answer 84

A

Labs:
a. Electrolytes, Glucose, BUN, Cr, CK, ABG

Treatment:

a. Benadryl for dystonic reactions (consider Haldol)
b. Bicarb for QRS prolongation
c. IVF and norepi or phenyl for hypotension
* Drugs with beta 2 activity may worsen hypotension (vasodilation)
d. Mag or pacing for QT prolongation
e. Charcoal for decontamination
f. Dialysis NOT recommended

Answer 85

A

b. D2 antagonist
c. Produce psychomotor slowing, emotional quieting, and affective indifference
d. Side effects: EPS, dystonia, tardive dyskinesia, rigidity

phenothiazines are occasionally visible on plain abd xrays

Examples:
haldol, chlorpromazine, fluphenazine, loxapine

Answer 86

A

b. 5HT2a/D2 antagonists
c. Are “newer” and differ from other antipsychotics in their dopamine receptor binding
d. Dopamine/serotonin antagonist
e. Have less EPS side effect
f. Higher risk of metabolic side effects
- ex: hyperglycemia, weight gain, dyslipidemia.

Clozapine can cause hypersalivation, prolonged confusion, cardiac toxicity

Examples:
Fazaclo (clozapine), Zyprexa (olanzapine), Invega (paliperidone), Seroquel (quetiapine), Risperdal (risperidone), Geodon (ziprasidone), Abilify (aripiprazole)

Answer 87

A

Dopamine antagonist

Example:
Abilify aripiprazole

Answer 88

A

6.8 Identify the toxicity and symptoms of exposure to common antihypertensives.

Answer 89

A

a. Hypotension. Generally responsive to fluid therapy. Vasopressors not generally needed
b. Bradycardia has been reported
c. Hyperkalemia (may occur with therapeutic use). Esp in renal insufficiency and co-
ingestion of NSAIDS
d. Bradykinin mediated effects: dry cough and angioedema

Answer 90

A

Benazepril (Lotensin)
  Captopril.
  Enalapril (Vasotec)
  Fosinopril.
  Lisinopril (Prinivil, Zestril)
  Moexipril.
  Perindopril.
  Quinapril (Accupril)

Answer 91

A

Azilsartan (Edarbi)
    Candesartan (Atacand)
    Eprosartan.
    Irbesartan (Avapro)
    Losartan (Cozaar)
    Olmesartan (Benicar)
    Telmisartan (Micardis)
    Valsartan (Diovan)

Answer 92

A

b. Decrease sympathetic outflow. s/s: sedation, miosis, early hypertension followed by bradycardia and hypotension

Examples:
gunabenz, guanfacine, clonidine, tizanidine

Answer 93

A

a. n/v, dehydration, electrolyte abnormalities
i. Hypokalemia, hypomagnesemia, hyponatremia, hypochloremic alkalosis
ii. Electrolyte imbalance may cause arrhythmias and enhance digitalis toxicity

b. Treat with hydration and electrolyte repletion as needed
c. OD generally benign

d. Spironolactone & Triamterene
i. may cause hyperkalemia (K sparing)
ii. spironolactone slow onset

e. Furosemide and Ethacrynic acid
i. high dose/rapid IV admin (esp to pts in renal failure) may be ototoxic

f. Thiazides
i. may cause hyperglycemia, hypercalcemia, hyperuremia

g. Carbonic anhydrase inhibitors
i. may cause metabolic acidosis
ii. acetazolamide, dichlorphenamide, methazolamide

Answer 94

A

b. Dilate peripheral arterioles to lower BP.
c. Reflex tachycardia and occasionally cardiac arrhythmias may or may not occur

*OD may cause headache, nausea, dizziness, weakness, syncope, orthostatic hypotension, warm flushed skin, palpitations. Lethargy and ataxia may occur in children.

Examples:
Minoxidil, hydralazine, diazoxide, Alpha Adrenergic Blockers, phentolamine, prazosin, doxazosin, terazosin, tamsulosin

Answer 95

A

6.9 Identify the toxicity and symptoms of exposure to beta blockers and calcium channel antagonists.
Given an exposure to a beta blocker or calcium channel blocker, identify the appropriate treatment.

Answer 96

A

Action: Type II antiarrhythmic

S/S:

i. Cardiac: 1 st degree AV block; hypotension; bradycardia most common
ii. CNS depression/sz
iii. Bronchospasm
iv. Hypoglycemia/Hyperkalemia

Treatment:

i. Monitor BS Q2H unless severely symptomatic
ii. Glucagon followed by Epinephrine (bradycardia/hypotension)
iii. High dose insulin with glucose infusion (bradycardia/hypotension)
iv. Isoproterenol (bradycardia/hypotension)
v. Bicarb (wide QRS)
vi. Isoproteranol, Magnesium, Overdrive pacing (torsades)

Answer 97

A

Examples:
Acebutolol (Sectral), Atenolol (Tenormin), Bisoprolol (Zebeta), Metoprolol (Lopressor, Toprol XL), Nadolol (Corgard), Nebivolol (Bystolic), Propranolol (Inderal, InnoPran XL)

Answer 98

A

Action: decrease Ca entry into cells, primarily acts on cardiac and vascular smooth muscle

 i. Coronary and peripheral vasodilation
 ii. Reduced cardiac contractility
 iii. Slowed AV conduction
 iv. Depressed sinus node activity
* *Create increased need for heart to use carbohydrate metabolism but inhibit pancreas from releasing insulin

S/S:

 i. Hypotension
 ii. Bradycardia, sinus arrest with junctional, or AV blocks
 iii. Prolonged PR or QT (normal QRS)
 iv. Depressed mental status
 v. Metabolic acidosis (from hypotension)
 vi. Hyperglycemia (blockade of insulin release), hypokalemia

Treatment:

 i. Check blood sugar
 ii. IVF for volume expansion (NS or LR)
 iii. Calcium reverses depression of cardiac contractility
 iv. Insulin/Glucose (HIE therapy)
 v. Lipids
 vi. Epi drip (or dopamine/norepinephrine)
 vii. Glucagon drip
 viii. Charcoal
 ix. Dialysis not effective

Answer 99

A

Norvasc (amlodipine)
Plendil (felodipine)
DynaCirc (isradipine)
Cardene (nicardipine)
Procardia XL, Adalat (nifedipine)
Cardizem, Dilacor, Tiazac, Diltia XL (diltiazem)
Sular (Nisoldipine)
Isoptin, Calan, Verelan, Covera-HS (verapamil)

Answer 100

A

Ex Digoxin

Act by inhibition of sodium-potassium-ATPase pump

a. Hyperkalemia *
b. Vagal tone (slowed rate and conduction)

Toxic interactions

a. Amiodarone
b. Verapamil
c. Quinidine
d. Macrolide antibiotics

S/S:
Acute
     i. GI s/s
     ii. Hyperkalemia *
     iii. Cardiac arrhythmias (brady and tachy). Almost any rhythm possible, but NOT likely to see afib.

Chronic

 i. GI
 ii. Visual disturbances (flashing lights, halos, green-yellow perceptual impairment)
 iii. Neuro (weakness)
 iv. Cardiac arrhythmias (classic bidirectional vtach)

**low K+ and Mag+ from diuretics worsen arrhythmias

Treatment:

i. Digifab
ii. Ca+, bicarb, insulin, etc for hyperkalemia
iii. Correct mag
iv. Atropine or pacing for brady
v. Charcoal
vi. Dialysis is NOT useful

Answer 101

A

6.11 Identify the toxicity and symptoms of exposure to over-the-counter stimulants and weight-loss
preparations.

Answer 102

A

a. Psychoactive effects in OD; mildly stimulating, euphoric or hallucinogenic properties

b. Described as depressant and sometimes hallucinogenic effect in large doses similar to
ketamine and PCP
i. When taken mixed with soda for flavor is called robo-tripping or skittling
ii. Can also be injected

Answer 103

A

a. Was used in diet pills. Used by athletes to enhance performance. Similar to amphetamine. Use as fat burner. Can be used as a substitute for ecstasy.
b. Adverse effects: n/v, dizziness, palpitations, hyperthermia, psychosis, stroke, sz, MI.

Answer 104

A

a. Coffee, energy drinks, pills, energy boosters

Answer 105

A

a. For weight loss

Answer 106

A

a. For opioid effect, esp when used with tonic water to cross blood brain barrier

Answer 107

A

a. Active ingredient in decongestants. Used for euphoria & stimulant effect
b. Used for production of methamphetamine

Answer 108

A

a. Antihistamine in higher doses produce mild euphoria, relaxation, hallucinations similar to those from LSD and mushrooms

Answer 109

A

a. For euphoric high and potentially hallucinations

Answer 110

A

Act as a sympathomimetic

i. Stimulates central alpha (inhibition of norepi and decrease sympathetic outflow)
ii. Used for decongestants
iii. Should not be used with buproprion, MAOIs, other NDRIs.

S/S:

i. Vomiting, mydriasis, HTN, tachycardia, agitation/ anxiety, reflex brady.
1. Severe dysrhythmias can occur.
2. Hypertension
a. Can cause ICH, MI
b. May see reflex bradycardia or AV block in attempt to regulate HTN

Labs:
i. Electrolytes, glucose, BUN, Cr, CK, troponin

d. Treat HTN
Use a vasodilator such as phentolamine or nitroprusside
ii. Do not use beta blockers alone to treat hypertension unless first using a vasodilator. Paradoxic worsening of the hypertension may result
iii. Treat tachyarrhythmias with esmolol or metoprolol
iv. Do not treat reflex bradycardia or AV block except indirectly by lowering blood pressure.
v. May use charcoal
vi. Dialysis not effective

Answer 111

A

a. Imidazole toxicity with miosis, bradycardia, hypotension, resp depression, CNS depression

Answer 112

A

a. supratherapeutic use can cause hepatic/renal toxicity

Answer 113

A

a. Nonamphetamine appetite suppressant also has antidepressant effects d/t blockade of
norepi, serotonin & dopamine reuptake

Answer 114

A

Diethylproprion HCl (Tenuate Dospan) is amphetamine like anorectant agent
Orlistat (Xenical) limits absorption of dietary fat. It may cause diarrhea in OD.

Answer 115

A

6.12 Identify the toxicity and symptoms of exposure to antidiabetic agents. Given a patient with an overdose of an antidiabetic medication, identify the appropriate treatment.

Answer 116

A

a. Slow the absorption of starches you eat
b. GI s/s (bloating, flatulence, abd pain, diarrhea); possible electrolyte abnormalities
c. Contraindicated in bowel problems

Examples:
acarbose (Precose), miglitol (Glyset), Voglibose

Answer 117

A

a. Inhibits insulin degradation48
b. No significant hypoglycemia

Examples:
Vildagliptin, Sitagliptin, Saxagliptin

Answer 118

A

i. Onset < 15 min
ii. Peak 30-90 min
iii. Duration 3-5 hrs

Answer 119

A

i. Onset 30-60 min
ii. Peak 2-4 hrs
iii. Duration 4-8 hrs

Answer 120

A

i. Onset 1-2 hrs
ii. Peak 4-10 hrs
iii. Duration 10-18 hrs

Answer 121

A

i. Onset: 1-2 hrs
ii. Peak: none
iii. Duration 20-24 hrs

Answer 122

A

i. Onset: <15 min-1 hr
ii. Peak: 1-10 hrs
iii. Duration: 10-18 hrs

Answer 123

A

a. Is a Biguanide antidiabetic medication
i. Decrease the amount of glucose made by the liver. Generally does not cause hypoglycemia
ii. May have lactic acidosis
iii. Dialysis for lactic acidosis and to clear metformin

Examples:
Glucophage, Glumetza

Answer 124

A

a. Meglitinides
i. Stimulates insulin secretion
ii. Can cause hypoglycemia.
iii. Treat with dextrose

Answer 125

A

a. Increases urinary glucose excretion.
b. Not expected to cause hypoglycemia alone, but may when combined with insulin or
insulin secretagogues

Examples:
scanagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance)

Answer 126

A

a. Increase insulin secretion. Can cause prolonged and delayed hypoglycemia.
b. Tx Octreotide or Diazoxide for OD (inhibit insulin secretion)
c. Watch for hyponatremia d/t induction of SIADH

Answer 127

A

Examples: DiaBeta, Glynase, or Micronase (glyburide or glibenclamide) Amaryl (glimepiride) Diabinese (chlorpropamide) Glucotrol (glipizide) Tolinase (tolazamide) Tolbutamide.

Answer 128

A

a. Make you more sensitive to insulin
b. No significant hypoglycemia
c. May cause fluid retention; peripheral edema; possible hepatotoxicity

Examples:
Rosiglitazone (serious cardiac adverse effects)
Pioglitazone
Troglitazone (off market d/t liver failure)

Answer 129

A

T3: triiodothyronine
a. dose 0.75mg considered toxic.
b. SE may be manifest within first 6 hrs.
T4: levothyroxine
a. dose 5mg considered toxic.
b. SE may be delayed 2-5 d for T4 to be metabolized to T3
Watch for adrenergic activity in GI, cardio, neuro.
* Ex: tachycardia, hyperthermia, flushing,
diarrhea, vomiting, headache, anxiety. Severe toxicity may see sz/hypotension.
In massive T4 ingestion may use propylthiouracil or iopanoic acid to inhibit change into T3
Treat tachyarrythmias with propranolol or esmolol.
Charcoal is appropriate; Dialysis not useful.

Answer 130

A

Total amount iron ingested per unit of body weight

[total # tablets] [weight (mg) per tablet] [% elemental Fe per tablet] / [pt weight (kg)]

Elemental iron in formulations
a. Ferrous gluconate 12% (11% - “911”)
b. Ferrous sulfate 20% (22% - “backwards 2”)
c. Ferrous fumarate 33% (33% -“full”)
Toxic dose
a. >= 10mg/kg GI effects
b. >= 40mg/kg systemic effects
c. >=60mg/kg potentially lethal

Answer 131

A

The clinical course of iron toxicity is divided into five stages. The progression from stage to stage may be very rapid, and not every patient goes through every stage.

During the first stage (0.5 to 6 hours), the patient mainly exhibits gastrointestinal (GI) symptoms including abdominal pain, vomiting, diarrhea, hematemesis, and hematochezia.
The second stage (6 to 24 hours) represents an apparent recovery phase, as the patient’s GI symptoms may resolve despite toxic amounts of iron absorption.
The third stage (6 to 72 hours) is characterized by the recurrence of GI symptoms, shock, and metabolic acidosis. Iron-induced coagulopathy, hepatic dysfunction, cardiomyopathy, and renal failure are also observed in this stage.
The fourth stage (12 to 96 hours) is characterized by an elevation of aminotransferase levels and possible progression to hepatic failure.
The fifth stage (2 to 8 weeks) represents the consequences of the healing of the injured GI mucosa including pyloric or proximal bowel scarring and obstruction.
* A patient may present in or skip any of the five stages. Determination of the iron toxicity stage should be based on symptoms and clinical manifestations and not on time of ingestion.

Answer 132

A

a. May have elevated WBC (>15k); hyperglycemia (>150mg/dL); radiopaque material on abd xr. Symptomatic presentation and history.

Labs:

a. Initial iron level (ideally 4-6 hrs after ingestion)
b. Repeat iron level (8-12 hrs after ingestion to ensure not rising from ER or bezoar)

Answer 133

A

a. Deferoxamine (IV preferred over IM)
i. Use for shock, severe acidosis, or iron level >500mcg/dL
ii. Watch for vin rose color or urine (does not always occur)
iii. Stop infusion when UOP color returns to normal OR when iron level return to normal range
iv. **deferoxamine longer than 36-72hrs associated with Yersenia sepsis

b. Gastric lavage only if liquid ingested or chewed tablets
c. Do NOT use phosphate containing or sodium bicarb solutions for lavage!!!!
d. Consider whole bowel for tablet ingestion
e. No charcoal
f. No dialysis for iron (may use dialysis to remove deferoxime/iron complex with renal failure

Answer 134

A

major toxic effect is CNS depression

Answer 135

A

a. Sedative-hypnotic
i. Used for anesthesia induction, sz, and pain. High abuse potential
ii. Varying length of action (ultra-short to long acting)
iii. Increase GABA

b. S/S
i. CNS depression
ii. Barbiturate burns

c. Treatment
i. Supportive care
ii. Charcoal
iii. Alkalization of urine for phenobarbital OD
iv. Dialysis increases elimination of long acting agents but rarely used

Barbiturate coma resembles brain death*
1. Cannot withdraw care until documenting nontoxic barbiturate levels

Answer 136

A

a. Sedative-hypnotic
i. Used for sedation, anxiolysis, and seizure management
ii. Increase GABA

b. S/S
i. CNS depression. Increased when combined with other drugs such as barbiturates and ethanol
ii. Hypotension, hypothermia, memory impairment, lethargy, ataxia

c. Treatment
i. Flumazenil for benzo naïve or to prevent difficult/dangerous procedure

Answer 137

A

a. May cause n/v, drowsiness, miosis

b. serotonergic

Answer 138

A

a. Metabolized to trichloroethanol, also has CNS depressant activity
b. May sensitize myocardium to catecholamines (arrhythmias)

Answer 139

A

a. CNS depression. Is not a benzo but has similar effects.

Answer 140

A

a. CNS depression. GABA agonist. Have seen methemoglobinemia in very large OD.

Answer 141

A

Skeletal muscle relaxant (sedative-hypnotic that affects muscle indirectly)

Answer 142

A

a. Expect CNS depression, n/v, hypotension, etc

Answer 143

A

a. may cause muscular hypertonicity, clonus, hyperreflexia

Answer 144

A

a. Anticholinergic/serotonergic s/s from carisoprodol

b. Large OD may cause concretions. May cause hypotension.

Answer 145

A

a. Anticholinergic (tachy, mydriasis, delirium); hypotension

b. Orphenadrine only: status epilepticus, Vtach, asystole

Answer 146

A

a. Coma, resp depression, bradycardia, paradoxical seizure like activity, delirium,
AV dysfunction

Baclofen can mimic brain death

Answer 147

A

a. Similar to clonidine

b. Coma, profound hypotension, bradycardia, SA and AV node dysfunction

Answer 148

A

a. Flumazenil may work for chlorzoxazone and carisoprodol
b. Physostigmine may reverse anticholinergic s/s with cyclobenzaprine and orphenadrine (may cause seizures)
c. Dialysis: possibly for symptomatic baclofen with impaired renal function

Answer 149

A

Ex MDMA, meth, dextroamphetamine (Dexedrine), methylphenidate (Ritalin)
a. Schedule II drug

b. Toxidrome
i. Sympathomimetic
ii. Serotonergic

c. Treatment
i. Benzos (agitation, seizures); may add antipsychotic
ii. Phentolamine or nitroprusside for HTN if not treated with benzo
iii. Propranolol or esmolol for tachyarrhythmias (paradoxical HTN may occur requiring a vasodilator)
iv. Charcoal
v. Dialysis not effective

Answer 150

A

Slang:
a. Speedball (cocaine and heroin)
b. Crack (free base). Most addictive form
Use: snorted, smoked, injected, oral
a. May be adulterated with lidocaine, benzocaine, stimulants, or levamisole (causes
agranulocytosis)
MOA
a. Blocks reuptake of norepi, dopamine, and serotonin
b. Na+ channel blockade (neuronal and cardiac)
c. Metabolized plasma/liver

Answer 151

A

a. Stroke (ischemic/embolic/ICH)
b. MI
c. Arrhythmias
i. QRS and QTc prolongation
d. Sz (usually brief)
i. Status reflects continued absorption of drug (ruptured packing) or hyperthermia
e. Anxiety/agitation
f. HTN/tachycardia
g. Muscle rigidity
h. Hyperthermia

Answer 152

A

a. Electrolytes, glucose, BUN, Creatinine, CK, urinalysis and urine myoglobin, Trop, ECG, CT,
abd x-ray (body packing)

Answer 153

A

a. Benzodiazepines for anxiety, hypertension, tachycardia
* DO NOT USE BETA BLOCKERS*

If HR/BP refractory to benzos and IVF, consider cardioselective BB such as esmolol or metoprolol. May be used with vasodilator such as phentolamine for HTNii. Bicarb for QRS prolongation
iii. Lidocaine for wide complex tach

Answer 154

A

6.19 Identify the toxicity and symptoms of exposure to street drugs.

Answer 155

A

Stimulants, Hallucinogens, Street drugs

Answer 156

A

i. methemoglobinemia

Answer 157

A

i. S/S OD (Caffeine)
1. Tremor
2. Vomiting
3. Tachycardia
4. Seizures (can be refractory)
5. Hypokalemia
6. Hyperglycemia

ii. Labs
1. May draw a theophylline level (it is a metabolite of caffeine)

iii. Treatment
1. Benzos for seizures
2. Beta blockers (propranolol or esmolol) for tachyarrhythmias and hypotension
3. Vasopressin/phenylephrine for hypotension
4. Charcoal
5. Dialysis

Answer 158

A

i. Abrupt onset of sleep, enuresis, myoclonic movements, bracycardia, coma

Answer 159

A

i. CNS/resp depression. Miosis. Pulmonary edema

ii. Reverse with narcan

Answer 160

A

i. Hallucinogen/Enactogen
1. Examples: LSD, MDA, MDMA

ii. Use: snorted, smoked, injected

iii. S/S
1. Cardiac:
a. HTN, tachycardia
2. Neuro
a. Anxiety, psychosis, hallucinations, dilated pupils, tremor, hyperreflexia
3. Metabolic
a. Hyperthermia & Sweating

iv. Labs
1. Include PT (untreated hyperthermia can result in coagulopathy)
2. CK and urine blood/myoglobin (rhabdomyolysis)

v. Treatment
1. Supportive care
2. Diazepam, midazolam, Haldol for severe agitation
3. No charcoal or dialysis

Answer 161

A

i. Slang terms: Hashish, Kief, Bhang, Budder
ii. Use: oral or smoked

iii. S/S
1. Cardiac
a. Tachycardia and orthostatic hypotension
2. Neuro
a. Slurred speech and ataxia
3. Other
a. Conjunctival erythema
b. Decreased IOP

iv. Treatment
1. Supportive care
2. s/s requiring treatment generally due to co-ingestions

Answer 162

A

i. S/S
1. Cardiac
a. Tachycardia, HTN,
2. Neuro
a. Hallucinations, euphoria, disinhibition.
3. Other
a. Nystagmus often prominent
4. Severe toxicity may cause psychosis, hyperthermia, rhabdo, organ failure, acidosis, sz.

Answer 163

A

i. Sympathomimetic toxidrome.

ii. This is a general class and includes amphetamines, cathinones, cocaine, ephedrine, etc.

Answer 164

A

i. Sympathomimetic toxidrome.

ii. May see paranoia, delirium, aggressive behavior, hallucinations, hyperthermia,
hypotension, rhabdo, dysrhythmias.

Answer 165

A

6.20 Identify the toxicity and symptoms of exposure to over-the-counter topicals.

Answer 166

A

Antiseptics (i.e. mercurochrome, iodine)

Answer 167

A

i. No significant absorption if applied topically; ingestion poses risk

Answer 168

A

i. Can be corrosive

ii. Antidote for ingestion is starch (cornstarch, potatoes)

Answer 169

A

i. Corrosive in higher concentration

Answer 170

A

i. Irritating to skin and resp tract. May cause dermatitis/ocular damage

Answer 171

A

i. Related to phenol but less toxic. Found in anthelmintics and throat lozenges. Has vesicant properties

Answer 172

A

i. may cause gastric distention, perforation, air emboli. More commonly in industrial concentrations.

Answer 173

A

i. (sometimes found in antiseptic mouth wash)

corrosive burns, methemoglobinemia

Answer 174

A

i. corrosive

Answer 175

A

i. GI irritation/bleeding

Answer 176

A

i. Multiple sources: clove oil has eugenol; Lysol has bisphenol; creosote, etc.
ii. Well absorbed via multiple routes
iii. Denatures protein, disrupts cell wall, causes coagulative tissue necrosis, corrosive injury to eyes, skin and resp tract. Some may cause methemoglobinemia, CNS stimulation, cardiac arrhythmias
iv. Dx based on history of exposure, presence of characteristic odor (sickeningly sweet and tarry); painless skin burns with white discoloration

Answer 177

A

i. oral irritation, CNS depression, bradycardia, hypotension

Answer 178

A

Camphor, Methyl Salicylate, and Other Essential Oils

Answer 179

A

i. 98% methyl salicylate or 1.4g ASA/ml

ii. Aspirin toxicity

Answer 180

A

i. CNS stimulant. Oral irritation, n/v, sz 20-30 min s/p ingestion.

Answer 181

A

i. Stomatitis and skin burns. Smoked as hallucinogen

Answer 182

A

i. 80-90% eugenol. Metabolic acidosis, CNS depression, sz, coagulopathy, hepatotoxicity. May treat with NAC

Answer 183

A

i. Acidosis, multi organ system failure

Answer 184

A

i. Nontoxic

Answer 185

A

i. CNS depression; May cause photosensitization

Answer 186

A

i. Tea tree oil. Toxic peds dose is 10ml. sedation, confusion, ataxia, coma. Onset 30-60min.

Answer 187

A

i. Is an alcohol; may cause oral irritation, emesis, tremor, ataxia, CNS depression

Answer 188

A

i. Hallucinogen and amphetamine like effect/psychogenic effects

Answer 189

A

i. Moderate to severe toxicity with >10ml. coma, hepatotoxicity. Abortifacient. May treat with NAC

Answer 190

A

i. 50% menthol. Oral irritation, emesis, tremor, CNS depression, bradycardia, metabolic acidosis

Answer 191

A

i. Allergic dermatitis (used as antiseptic)

Answer 192

A

i. 98% methyl salicylate or 1.4g ASA/ml

ii. Aspirin toxicity

Answer 193

A

Minerals and Electrolytes
a. Iron-see above

b. Fluoride
i. Hypocalcemia, n/v
c. Other Minerals
i. GI upset

Answer 194

A

6.22 Identify the toxicity and symptoms of exposure to other drugs.

Answer 195

A

Anticholinergics-see toxidrome

Answer 196

A

a. Heparin
b. Newer anticoagulants (i.e. dabigatran and rivaroxaban)
c. Warfarin/Rodenticides/Super Coumadins

Answer 197

A

i. Check PTT

ii. Protamine sulfate is reversal agent

Answer 198

A

i. Thrombin inhibitor (dabigatran)
1. Reverse with Idarucizumab
a. Humanized, monoclonal antibody fragment

ii. Xa inhibitor (Rivaroxaban, apixaban, endoxaban)
1. Reverse with Andexa

Answer 199

A

i. Check INR
ii. Vitamin K is reversal agent,
iii. FFP or whole blood for clotting factors; recombinant factors

Answer 200

A

a. Action

i. H1 blockers have two types:
1. 1 st generation more lipid soluble and cross blood-brain barrier
a. Sedating
b. Ex benadryl, promethazine, meclizine, chlorpheniramine

2nd generation less lipid soluble and do not cross BBB
a. Nonsedating
b. Ex loratadine (Claritin), desloratadine (Clarinex), cetirizine (Zyrtec), fexofenadine (Allegra)

ii. H2 blockers delay gastric emptying; do not share other effects and do not produce significant intoxication (cimetidine, famotidine, nizatidine and ranitidine)

Answer 201

A

i. Anticholinergic effects (antimuscarinic) and Na channel blockade
ii. May have rhabdo
iii. QRS and QT prolongation with some

Answer 202

A

c. Labs
i. Electrolytes, glucose, CPK

d. Treatment
i. Benzos for sz, hyperthermia, agitation
ii. Aggressive cooling
iii. Bicarb for QRS
iv. Physostigmine with caution (for anticholinergic)
v. Take care with antiarrhythmic use (some will worsen s/s)
vi. Charcoal
vii. Dialysis not effective

Answer 203

A

Gastrointestinal Agents

Answer 204

A

i. Antidiarrheal agent

ii. Onset of s/s d/t atropine may be delayed 6-8 hrs or longer. Coma/resp depression may be delayed up to 30 hrs

Answer 205

A

i. Antidiarrheal agent
ii. Popular drug of abuse
iii. Drowsiness, n/v, abd pain, headache. Miosis is common. Bradycardia/resp depression can occur. Cardiac dysrhythmias have been reported in large doses of med abuse.

Answer 206

A

i. Antiemetic/prokinetic agent. Blocks dopamine and serotonin receptors.
ii. Inadvertent OD in infants has caused methemoglobinemia and opisthotonic posturing
iii. Dystonic reactions more common in children and young adults
iv. NMS may occur
v. Common toxic effects are restlessness, drowsiness, insomnia, headache, confusion, dizziness, and dystonic reactions

Answer 207

A

a. Erectile Dysfunction Agents
i. Sildenafil (Viagra); Tadalafil (Cialis); Vardenafil (Levitra)
ii. PDE5 inhibitor
iii. Headache, flushing, dizziness, weakness, priapism, vertigo, hypotension, tachycardia, weakness

b. Phenazopyridine (Pyridium)
i. Urinary anesthetic
ii. Methemoglobinemia/hemolytic anemia

c. Urinary Antispasmodics
i. Oxybutyin (Ditropan), Hyoscyamine, Solifenacin
1. Anticholinergic s/s

Answer 208

A

a. Steroids
i. Acute ingestion unlikely to cause toxicity
ii. Chronic exposure to high doses may result in adverse effects

Answer 209

A

a. Methemoglobinemia

b. Cardiac toxicity

Answer 210

A

a. Antineoplastic agent, used for RA or psoriasis

b. GI upset, pancytopenia, ALI, resp failure, sepsis

Answer 211

A

a. Antihelmenthics (i.e. heartworm products)

b. Vaccines (live vaccines can cause a problem ex brucellosis)