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Pharm Exam 1 > The Poisoned Patient - I and II > Flashcards

The Poisoned Patient - I and II Flashcards

1
Q

Stabilization - ABCs

A

Airway, Breathing, Circulation (support c-spine)

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2
Q

All patients with altered mental status must immediately be given these four substrates:

A

1 Oxygen

2	Naloxone (narcotic antagonist)
Except in certain patient populations:
Opioid dependent without apnea or severe respiratory depression
History of “speedball” abuse
Agitated/seizing
Pregnant and opioid dependent
  1. Thiamine (to reverse or prevent Wernicke’s)
  2. Glucose (rapid determination or bolus with dextrose)
    Note: glucose may precipitate Wernicke’s and therefore is usually given with thiamine
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3
Q

Physical exam
Start with the vital signs

Hypoventilation:

Hyperventilation:

Bradycardia: (big 4)

Tachycardia:

Hypotension:

Hypertension:

Hypothermia:

Hyperthermia:

A

Always start with vital signs: pulse rate and pupillary size may be most helpful

Hypoventilation: opiods, sedative-hypnotics

Hyperventilation: generally non-specific; seen more often with stimulants

Bradycardia: beta blockers, Ca++ channel blockers, clonidine and digitalis (big 4)

Tachycardia: non-specific

Hypotension: many agents

Hypertension: many agents

Hypothermia: ethanol is the number one cause in Detroit; antipsychotics (effects on hypothalamus make the patient vulnerable to environmental temperature changes)

Hyperthermia: amphetamines (ie. MDMA), anticholinergics

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4
Q

Eye Changes:

A

Eye Changes:

Mydriasis: not very helpful unless very dramatic (anticholinergics like atropine)

Miosis: cholinergics

Nystagmus: sedative hypnotics, PCP/ketamine (vertical, horizontal and rotary)

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5
Q

Characteristic Odors:

A

Bitter almonds: cyanide

Rotten eggs: mercaptans

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6
Q

How do opioids and cholinergics differ?

A

Bowel sounds are hyperactive with choinergics and decreased with opioids

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7
Q

How do Anticholinergics and Sympathomimetics differ?

A 
Anticholinergics = dry, red, hot skin
Sympathomimetics = sweaty
Anticholinergics = decreased bowel sounds
Sympathomimetics = normal bowel sounds
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8
Q

Anion gap =

Normal =

A

Anion Gap= Na – (HCO3 + Cl)

normal is 12 +/- 4 meq/L

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9
Q

Toxins Causing High Anion Gap

A 
MUDPILES
o	Methanol/metformin
o	Uremia
o	Diabetes (ketoacidosis)
o	Paraldehyde/phenformin/propylene glycol
o	Iron/isoniazid
o	Lactate (theophylline/cocaine)
o	Ethylene glycol
o	Salicylates
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10
Q

Toxins Causing Low Anion Gap:

A

Toxins Causing Low Anion Gap:
o Lithium
o Bromide

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11
Q

Measured Osmolality:

Calculated Osmlality:

Osmolal Gap=

A

By freeing point depression or boiling point elevation (only freezing point depression clinically useful)

Calculated Osmlality: 2 Na + (glucose/18) + (BUN/2.8)

Osmolal Gap= Measured Osmolality – Calculated Osmolality; normal should be less than 10

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12
Q

Toxin Causing Increase in Osmolal Gap:

A 
o	Methanol
o	Ethanol
o	Isopropanol
o	Ethyele glycol
o	Acetone
o	Osmotic diuretics (mannitol/glycerol)
  • Important Point: normal osmolal gaps do NOT rule out toxic alcohol ingestions
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13
Q

What is the gold standard of toxicology screening?

A

GC-Mass spectrometry

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14
Q
  • Some substrates will be radiopaque on x-ray (CHIPES)
A 
o	Cholral hydrate
o	Heavy metals
o	Iodine/iron
o	Phenothiazines/TCAs
o	Enteric coated
o	Solvents

Important Point: a negative radiograph does not rule out these substances

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15
Q

Substances that Classically Form Concretions (BIG MESS):

A 
Barbituates
o	Iron
o	Glutethimide
o	Meprobamate
o	ER Theophylline
o	Salicylates
o	Sedative-hypnotics
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16
Q

Ipecac

Stimulates:

Contraindication:

A

Ipecac: most effective emetic

Stimulates the chemoreceptor trigger zone (CTZ) and induces vomiting

By stimulating both central and peripheral (GI tract) receptors

Use in ER: decreasing because of the fact that it increases the time to administration of charcoal

Pre-hospital use is sometimes appropriate if administered by poison specialist

Contraindications:
Very young children (not able to walk or less than 6 months)
Absence of gag reflex
CNS depression or ingestion of a potentially CNS depressing agent
Corrosive substance ingestion

17
Q

Activated Charcoal

General process

Multidose charcoal therapy

Important point

Contraindications

A

General Process:
Contains network of tiny pores capable of trapping toxins

Directly adsorbs material to prevent its absorption (reversible binding)

Interrupts enterohepatic recirculation of some
drugs and their metabolites

Creates concentration gradient so that diffusible drugs enter the gut from the blood stream

Initial dose is 1g/kg of body mass (since it is often hard to determine how much of the toxic substance was ingested)

Multidose Charcoal Therapy: administered every 2 hours

  • Important Point: not all agents bind to activated charcoal
  • Metals, some pesticides, some alcohols poorly bound
  • Generally still advisable to give a dose of charcoal early on if substance ingested is unknown

Contraindications:

  • Corrosive injury to esophagus or GI tract
  • Intestinal obstruction
  • Ileus (obstruction of normal propulsive activity of the GI tract)
18
Q

Gastric Lavage:

Uses

A

Not employed routinely

If patient arrives within 60-90 minutes of ingestion of life-threatening substance

Altered mental status or critically ill patient within 60-120 minutes of ingestion

Later, if there are concretions, delayed gastric emptying or sustained released

Frequent complications

19
Q

Catartics

Commonly used ones:

Mechanisms:

Goal:

A

Commonly Used:
Saline (Mg citrate, Mg sulfate)
Saccharide (sorbitol)

Mechanism: add osmotic load to the gut

  • Large volumes of fluid in the gut
  • Increased small bowl peristalsis
  • Mg sulfate also stimulates release of CCK (increases motor and secretory action of GI tract)

Goal: allow the activated charcoal-drug complex to be removed from the body ASAP (prior to desorption, since charcoal reversibly binds)

  • Sorbitol is the most rapidly acting
  • Multiple doses may be dangerous (one dose per day generally)
20
Q

Whole Bowel Irrigation (golytely)

Uses:

Indications:

Contraindications:

A

Use: allows for mechanical cleansing of the gut without the risk of fluid or electrolyte imbalance

Potential Indications:

Ingestions of massive amounts of a toxic substance

Metals (do not adsorb to charcoal- iron or lithium, for example)

Sustained-release preparations

Body-packers (wrapped packages of illicit drugs)

Presence of concretions

Contraindications:
Inadequate airway protection
Obstruction
Ileus (bowel obstruction)
Perforation
21
Q

Ion Trapping (pH Alteration):

Mech
Alkalization of urine
Acidification of urine

A

Ion Trapping (pH Alteration):

Mechanism: drugs that are weak acids or weak bases ionize in solution

Renal excretion of certain drugs can be enhanced by ion-trapping in the renal tubule

Alkalization of Urine:
o	Salicylates
o	Phenobarbitol
o	2,4-D
o	Chlorpropamide

Acidification of Urine:
o Risk to patient outweighs potential benefit (causes rhabdomyolysis)

22
Q

Hemodialasis

Use:

Indications:

A

Use: depends on physical characteristics of toxin

Drug must be able to freely pass the dialysis membrane (low molecular weight, high water solubility, low protein binding, small volume of distribution)

Therefore, not a lot of things can be removed by dialysis

Indications:
o Salicylates
o Phenobarbitol
o Toxic alcohols (ethanol, methanol, ethylene glycol)
o Lithium
o Certain toxins in patients with renal failure

23
Q

Hemoperfusion

Use:

Mechanism:

Indications:

Complications:

A

Hemoperfusion:

Use: unlike dialysis, use is not limited by water solubility or molecular weight

Of particular benefit when the drug is highly protein bound

Mechanism: pump blood through a cartridge filled with charcoal or resin beads that remove drugs

Indications:
o Theophylline
o Others possible (anticonvulsants, colchicines)

Complications:
o	Thrombocytopenia 
o	Leukopenia
o	Reduced glucose and Ca++ levels
o	Hemorrhage secondary to heparinization
24
Q

Multidose Activated Charcoal

Use:

Indications

A

Use: several doses of activated charcoal given to enhance elimination (reversible binding, keeps things bound)

Via interruption of enterohepatic, enterogastric and enteroenteric circulation

Indications:
o	Phenobarbitol
o	Dapsone
o	Theophylline
o	Carbamazepine
o	Quinine 
o	Phenytoin (sometimes)
25
Q

Hyperbaric Oxygen:

Use:

A

Potentially of benefit in CO, CN and hydrogen sulfide poisonings (also possibly CCl4)

26
Q

Antidotes:

Antivenin:

Digoxin-Specific Antibodies (Digibind):

Cyanide Antidote Kit

Naloxone

N-acetylcysteine (Mucomyst)

Methylene Blue

Ethanol

Flumazenil

A

Antivenin: snake bites, black widow spiders, scorpions, jelly fish

Digoxin-Specific Antibodies (Digibind): Digoxin, variety of plants (ie. foxglove, lily of the valley)

Oxygen: carbon monoxide

Cyanide Antidote Kit: cyanide, hydrogen sulfide

Naloxone: opiates/narcotics, clonidine, dextromethophan

N-acetylcysteine (Mucomyst): acetaminophen, CCl4, pennyroyal oil, cyclopeptide mushrooms

Methylene Blue: drugs causing methemoglobinemia (patient will have dark blood)

Ethanol: methanol, ethylene glycol, glycol ethers

Flumazenil: benzodiazepines (however, not often given because it can precipitate withdrawal, which is life threatening)

27
Q

Other Antidotes:

Atropine

Calcium

Glucagon

Glucose

Hydroxocobalamin

Pralidoxime (2-PAMCl)

Protamine

Pyridoxine (Vitamin B6)

Thiamine

Vitamin B12a

A

Atropine: Organophosphates, Carbamate, Physostigmine, Clitocybe/Inocybe mushrooms

Calcium: Hydrofluoric acid, Calcium channel blocker

Glucagon: Beta blockers, Calcium channel blockers, Insulin/oral hypoglycemic agents

Glucose: Insulin/oral hypoglycemic agents

Hydroxocobalamin: (Vitamin B12a) Cyanide

Pralidoxime (2-PAMCl): Organophosphates, Carbamates

Protamine: Heparin

Pyridoxine (Vitamin B6): Isoniazid, Gyromitra esculenta, Ethylene glycol, Disulfiram, Carbon disulfide

Thiamine: Ethanol, Ethylene glycol

Vitamin B12a: Cyanide, nitroprusside

Pharm Exam 1 (23 decks)

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