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Clinical Practice > Therapeutics and Toxicology > Flashcards

Therapeutics and Toxicology Flashcards

1
Q

what are the causes of constricted pupils?

A

opiates
organophosphates
barbiturates

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2
Q

what are the causes of dilated pupils?

A

atropine
amphetamines
cocaine
tricyclic antidepressants

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3
Q

what are the causes of nystagmus?

A

phenytoin
carbamazepine
barbiturates

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4
Q

what are the causes of burns in mouth?

A

caustics

corrosives

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5
Q

what are the causes of hypothermia?

A

chlorpromazine

barbiturates

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6
Q

what are the causes of skin blisters?

A

barbiturates

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7
Q

what are the causes of hypertension?

A

amphetamines
cocaine
ketamine
fentanyl

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8
Q

what are the causes of cardiac arrhythmias?

A

anticholinergic drugs
solvents
hallucinogens

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9
Q

what are the causes of behavioural disturbances?

A 
tricyclic antidepressants
phenothiazines
mefenomic acid
theophylline
salicylates
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10
Q

what are the causes of seizures?

A 
tricyclic antidepressants
phenothiazines
mefenomic acid
theophylline
salicylates
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11
Q

what are the causes of hypoglycaemia?

A

insulin
oral hypoglycaemics
ethanol

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12
Q

what are the causes of hypokalaemia?

A

salbutamol
theophylline
salicylates

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13
Q

what are the causes of metabolic acidosis?

A 
salicylates
ethanol
methanol
ethylene glycol
tricyclic antidepressants
paracetamol
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14
Q

what are the causes of increased osmolarity?

A

ethanol
methanol
ethylene glycol

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15
Q

what are the causes of increased INR?

A

warfarin

late paracetamol

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16
Q

what are the causes of increased AST and ALT

A

paracetamol

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17
Q

describe GI decontamination

A

GI lavage with the patient in a tilted downwards position
within 1 hour of ingestion of a potentially toxic amount of poison
protect airway
no corrosives
activated charcoal (single dose) only consider within 1 hour of the ingestion of a toxic amount of poison known to be absorbed to charcoal

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18
Q

what drugs may benefit from repeated activated charcoal?

A

carbamazepine
theophylline
phenobarbital
quinine

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19
Q

name some drug antidotes

A 
n-acetlycysteine (paracetamol)
naloxone (opioids)
sodium bicarbonate (tricyclic antidepressants)
vitamin k (warfarin)
flumenazil (benzodiazepines)
atropine (beta-adrenoceptor antagonists)
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20
Q

what are the signs of opioid toxicity?

A

respiratory depression
sedation
hypotension
pin-point pupils

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21
Q

what is the treatment of opioid toxicity?

A

0.8-2.0mg IV naloxone repeated until effect seen
usually rapid response
may precipitate withdrawal

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22
Q

what are the symptoms of paracetamol poisoning?

A

nausea, vomiting, abdominal pain, anorexia
vomiting, hepatic tenderness, mild jaundice
(severe untreated) jaundice, liver failure, encephalopathy, increased AST/ALT, bilirubin, creatinine, lactate, INR, decreased glucose, phosphate, platelets, factors II, V, VII

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23
Q

what is the treatment of paracetamol toxicity?

A

n-acetylcysteine IVI
commenced within 12 hours of ingestion
if in doubt treat
liver transplantation - pH < 7.30 delisted adequate fluid resuscitation or PT > 100s and creatinine >300mmol/L

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24
Q

what are the symptoms of tricyclic antidepressant toxicity?

A 
mostly anticholinergic/antimuscarinic
dilated pupils
blurred vision
hot dry skin
dry mouth
urinary retention
tachycardia
confusion
coma
convulsions
cardiac arrhythmia
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25
Q

what is the management of tricyclic antidepressant toxicity?

A

ABC/supportive care
increased risk of seizures/arrhythmia is QRS >100ms
very high risk if QRS >160ms and if R wave >3mm/abnormal QRS wave in aVR
ABG - metabolic acidosis
consider charcoal if significant OD <1hr before
sodium bicarbonate - QRS >160ms, metabolic acidosis, arrhythmia

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26
Q

describe the MOA and signs of benzodiazepine toxicity

A

enhance activity of inhibitory neurotransmitter gamma-aminobutyric acid (GABA)
signs - sedation, ataxia, coma, respiratory depression, hypotension

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27
Q

what is the problem with using flumenazil in benzodiazepine overdose?

A

may induce seizures and potentially fatal arrhythmias in
patients who have taken mixed ads (TCAs)
patients with a Hx of epilepsy
patients who are benzodiazepine dependent

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28
Q

what are the mechanisms of amphetamines?

A

cause CNS stimulation due to
release of catecholamines
inhibition of uptake of catecholamines
inhibition of monoamine oxidase

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29
Q

what are the clinical features of amphetamines?

A 
euphorias
talkativeness
anxiety (paranoia)
sympathomimetic syndrome - tachycardia, hypertension, hypertonia, hyperreflexia
arrhythmia - may be fatal
coma
convulsions
haemorrhagic stroke due to hypertensive surge
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30
Q

what are the specific features of ecstasy/MDMA?

A

hyperthermia
hyponatraemia
trismus/teeth grinding or other repetitive movements

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31
Q

what is the management of ecstasy/MDMA?

A

supportive care (ABC)
watch for hyperthermia
cardiac, bloods and ABG monitoring
agitation/repeated seizures - sedate with benzodiazepine
severely unwell - risk of liver/renal failure, hyperthermia, rhabdomyolysis, arrhythmias (see critical care support)

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32
Q

describe a type 1 hypersensitivity reaction

A

IgE and histamine release
e.g. anaphylaxis, atopy
immediate onset

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33
Q

describe a type 2 hypersensitivity reaction

A

antibody mediated phagocytosis

e.g. ABO, compatibility

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34
Q

describe a type 3 hypersensitivity reaction

A

immune complex deposition

e.g. serum sickness

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35
Q

describe a type 4 hypersensitivity reaction

A

T. cell mediated
e.g. contact dermatitis, Mantoux test
onset in hours/days

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36
Q

what are the causes of anaphylaxis?

A 
beta-lactam antibiotics (penicillins and cephalosporins)
contrast
neuromuscular blockers
anaesthetics
foods
insect stings
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37
Q

what are the signs and symptoms of anaphylaxis?

A 
urticaria
angiodema
flushing
pruritus
stridor
wheeze
cough
vomiting
abdominal pain
diarrhoea
hypotension
chest pain
dysrhythmia
collapse
38
Q

what is the treatment of anaphylaxis?

A 
ABCDE
immediate intubation if impending airway obstruction
remove the inciting agent
IM adrenaline
IV fluids
IM antihistamine (chlorphenamine)
IV hydrocortisone
nebuliser bronchodilators
refractory symptoms - IV adrenaline, vasopressors, glucagon, critical care support
39
Q

what test helps in the diagnosis of anaphylaxis?

A

mast cell tryptase
only take once stable
1-2 hrs after symptoms onset
repeat 24hrs later or at follow up

follow up - skin prick tests, drug/food challenge, specific IgE levels if available
avoidance advice
optimise asthma treatment
desensitisation

40
Q

define palliative care

A

active holistic care of people with advanced, progressive illness

41
Q

what is the treatment of dyspnoea in palliative care?

A

supportive - fans, pacing activities
pharmacological - oramorph, benzodiazepines (sublingual lorazepam 0.5mg)
oxygen if evidence of hypoxia

42
Q

what is the treatment of GI symptoms in palliative care?

A

treat constipation
drain ascites
anti-emetics -
H1 receptor antagonist (cyclizine) - inhibits emetic centre
pro-kinetic (metoclopramide) - encourages peristalsis
5HT3 receptor antagonist (ondansetron) - blocks vaguely inducted vomiting, constipating effect

43
Q

what are the causes of a unilateral swollen leg?

A 
DVT
ruptured baker's cyst
cellulitis
necrotising fasciitis
tumour
trauma
haematoma
arthritis (septic joint and crystal arthropathy)
compartment syndrome
superficial thrombophlebitis
44
Q

define cellulitis

A

a bacterial infection of the dermis and subcutaneous tissue
usually due to a break in the skin and an inflammatory response
usually caused by beta haemolytic streptococcus and staphylococcus aureus

45
Q

what are the symptoms and signs of cellulitis?

A

swelling
tenderness
redness
warmth over the affect area

46
Q

what are the causes of cellulitis?

A

pseudomonas aeruginosa - contaminated hot tubes, sponges, nail puncture
erysipelothrix rhusiopathiae - butches, vets, fish handlers
pasteurella multocida and capnocytophaga canimorsus - cat/dog bites
eikenella corrodens - human bite, fist injuries
streptobacillus moniliformis - rat bite

47
Q

what are the symptoms and signs of cellulitis?

A 
acute onset of red, painful, hot, swollen and tender skin
spreads rapidly
fever
malaise
nausea
shivering
rigours
break in the skin, blisters
inflamed regional lymph nodes or associated lymphangitis
red, linear streaks spreading proximally
48
Q

what are the risk factors for cellulitis?

A 
injury
IV drug use
elderly
previous cancer treatment
hospital stay
antibiotic use
obesity
DM
venous insufficiency
oedema
infection/animal bite
immunosuppression
skin conditions (eczema)
49
Q

what are the complications of cellulitis?

A

recurrent - damage of lymphatic drainage and chronic swelling
necrotising fasciitis - infection spreads to the fascial lining
septic abscess
myositis
worse outcome with diabetes

50
Q

what is the treatment of cellulitis?

A

mark area of skin to assess if spreading
flucloxacillin 1st line
calrithromycin or clindamycin alternatives
abscess - surgical drainage

51
Q

describe the pathophysiology of DVT

A

increases the hydrostatic pressure within veins by obstruction causing oedema
back pressure raises the capillary hydrostatic pressure and causes fluid to move out into tissues

52
Q

what are the signs of DVT?

A 
calf warmth
tenderness
swelling
erythema
mild fever
pitting oedema
homan's sign (discomfort behind the knee on forced dorsiflexion of the foot)
53
Q

what are the risk factors for DVT?

A 
>age
trauma
surgery (pelvic or orthopaedic)
previous DVT/PE
cancer
obesity
immobility
thrombophilia
dehydration
pregnancy
synthetic oestrogen
54
Q

how is the Wells’ score used?

A

score >2 then US performed within 4hrs
score <2 then D-dimer, if D-dimer is positive then US
US indicated but not performed with 4hrs - interim parenteral anticoagulant dose
score >2 and no DVT on US then follow up with a repeat US to confirm/exclude diagnosis

55
Q

what are the consequences of a DVT?

A

PE
cardiac arrest
post-thrombotic syndrome

56
Q

what is the treatment of a DVT?

A 
LMWH 1.5mg/kg OD
warfarin aim INR 2-3
NOACs
usually duration 3 months
cancer patients receive 6 months treatment
vena cava filters
percutaneous thrombectomy
57
Q

what is involvement in the prevention of a DVT?

A

stop the combined OCP 4 weeks pre-op
mobilise early during admission
LMWH for high risk patients after VTE assessment
graduated compression stockings
intermittent pneumatic compression devices

58
Q

what are the features of post-thrombotic syndrome?

A 
chronic leg swelling
pain
stiffness
aches
tingling
cramps
leg ulcers
59
Q

what are the causes of unilateral leg swelling?

A 
lymphoedema
ruptured baker's cyst, muscle, tendon, ligament, bursa
haematoma
superficial thrombophlebitis
cellulitis
60
Q

what is the mechanism of rivaroxaban?

A

direct factor Xa inhibitor

61
Q

what is the mechanism of dabigatran?

A

direct factor IIa/thrombin inhibitor

62
Q

what is the mechanism of apixaban?

A

direct inhibitor of activated factor X (factor Xa)

63
Q

what are the side effects of DOACs?

A 
abdominal pain
anaemia
dyspepsia
diarrhoea
haemorrhage
rash
thrombocytopenia
tachycardia
angiodema
64
Q

what is the differential diagnosis of a DVT?

A 
cellulitis
superficial thrombophlebitis
pelvic mass
chronic venous insufficiency
lymphoedema
65
Q

describe Virchow’s triad

A

3 factors that are important in the formation of thrombosis
venous stasis
vein damage
activation of blood coagulation

66
Q

describe PPIs (omeprazole, lansoprazole, pantoprazole, esomeprazole)

A

1st line PUD, reflux oesophagitis (GORD)

contraindications - warfarin, clopidogrel

irreversibly blocks the H+/K+ ATPase proton pump

adverse effects -
GI disturbance
headaches
increased risk of c diff
hyponatraemia
hypomagnesaemia
interstitial nephritis
rebound hyper secretion syndrome
67
Q

describe H2 receptor antagonists (ranitidine, cimetidine)

A

2nd line for PUD, reflux oesophagitis (GORD)

contraindications - inhibitor of CYP450 dependent metabolism (cimetidine>ranitidine)

adverse effects -
diarrhoea
confusion
gynaecomastia

68
Q

describe anti-dopamine agents (metoclopramide, domperidone, haloperidol, olanzapine, prochlorperazine)

A

anti-emetic

inhibits action of dopamine in CTZ, GIT and vomiting centre

metoclopramide - extrapyramidal side effects
domperidone - QT prolongation (torsade de pointes)

69
Q

describe anti-emetics (ondansetron, granisetron)

A

gastroenteritis
chemotherapy

5HT3 receptor antagonist

adverse effects - QT prolongation

70
Q

describe the eradication regimen for helicobacter pylori

A 
PPI/HR2A blocker
clarithromycin
amoxicillin (metronidazole if penicillin allergic)
triple therapy for 7 days
if complicated, continue PPI for 3 weeks

if due to start NSAID, should receive eradication therapy beforehand

71
Q

describe carbamazepine

A

generalised tonic-clonic seizures and partial seizures
neuropathic pain
mood stabiliser

adverse effects - diplopia, ataxia, sedation, fatigue, hyponatraemia, bone marrow suppression, hypersensitivity, hepatic derangement, rash

interactions - reduced effects of OCP, analgesics, anticoagulants, antivirals, steroids, statins, immunosuppressants

72
Q

describe phenytoin

A

generalised tonic-clonic seizures
status epilepticus protocol

adverse effects - dizziness, ataxia, fatigue, diplopia, nystagmus, rash, sedation, gum hyperplasia, hirsutism, osteopenia, low folate, fever, rash, teratogenicity, lymphadenopathy

73
Q

describe sodium valproate

A

all type of generalised seizures

appetite increase, weight gain
liver failure
pancreatitis
reversible hair loss
oedema
ataxia
teratogenicity
encephalopathy
74
Q

describe levetiracetam

A

1st choice for most seizure types
safe to use in pregnancy
avoid in psychiatric issues

blocks synaptic vesicle release

adverse effects - irritability, anxiety, fatigue, dizziness, behavioural changes, psychosis, hepatic failure

75
Q

describe lamotrigine

A

all types of generalised seizures
mood stabilising effects
safe to use in pregnancy

blocks Na channels and inhibits activated Ca channels

adverse effects - rash (can develop into Stevens-Johnson syndrome), insomnia

interactions - OCP, other AEDs

76
Q

describe topiramate

A

generalised tonic-clonic seizures
migraines
neuropathic pain

adverse effects - teratogenicity, appetite suppression, weight loss, psychiatric issues (avoid), word finding difficulty, renal calculi, acute angle closure glaucoma

77
Q

define status epilepticus

A

5 minutes of continuous seizure activity, or briefer seizures with non-recovery of consciousness between times

78
Q

what is the treatment of status epilepticus?

A

5 mins - 4mg lorazepam (repeat once at 10-15 min, max 0.1mg/kg)

15 mins - phenytoin 20 mg/kg

15 mins - anaesthetic drugs in ICU with EEG monitoring (propofol, midazolam, thiopentone)

79
Q

describe the management of T2DM

A

lifestyle measures
mono therapy - metformin
sulfonylurea - if the patient is not overweight, metformin not tolerated/contraindicated, rapid therapeutic response required

if HbA1c >48mmol/mol on maximum dose mono therapy, add second drug

80
Q

describe metformin

A

biguanide

reduces hepatic glucose output
increases glucose uptake

adverse reactions - nausea, vomiting, use with caution in sudden renal deterioration

81
Q

describe sulfonylureas (gliclazide 1st, glimepiride, glyburide)

A

T2DM management in those with no ketosis and no response to weight control and dietary therapy

stimulate the release of insulin from beta cells

adverse effects - hypoglycaemia (when used with alcohol, beta blockers, MAOI), weight gain, allergic reactions, pruritus, rash, hepatotoxicity, photosensitivity, hyponatraemia, water retention

82
Q

describe thiazolidinediones (pioglitazone)

A

step 3/4
stop after 6 months if HbA1c has not dropped by 0.5%

decrease insulin resistance and increase glucose uptake in skeletal muscle

adverse effects - hepatotoxicity, weight gain, hypos, increased risk of bladder cancer, HF, CVD risk, fracture risk

83
Q

describe GLP-1 analogues (liraglutide, exenatide, lixisenatide)

A

targeted at those who are overweight
sc injections

mimics the action of GLP1

adverse effects - GI disturbance, dizziness, dyspepsia, injection site reactions, pancreatitis risk, caution in renal disease, gastroparesis

84
Q

describe DPP IV inhibitors (sitagliptin, vildagliptin, saxagliptin, linagliptin)

A

2nd line after metformin/sulfonylureas
inhibits the breakdown of incretins-GLP 1
increases insulin and decreased glucagon

adverse effects - nasopharyngitis, URTI, headache, peripheral oedema, nausea, weight neutral/small weight gain, HF risk in the presence of heart or renal disease

85
Q

describe SGLT2 inhibitors (dapagliflozin, canagliflozin, empagliflozin)

A

add-on therapy to metformin and other glucose lowering drugs

block reabsorption in PCT preventing glucose reabsorption
doesn’t depend on insulin sensitivity

adverse effects -
reduced effectiveness in renal impairment
contraindicated in surgery and pregnancy
polyuria
increased UTIs
ketoacidosis
increased risk of AKI (especially in HF, diuretics, ACEis) and osteoporosis

86
Q

which medications should be stopped when a patient is on an opioid PCA?

A

concomitant oral opioids; dihydrocodeine

87
Q

what are the side effects of thiazide-like diuretics?

A 
erectile dysfunction
dehydration
postural hypotension
hyponatraemia
hypokalaemia
hypercalcaemia
gout
impaired glucose tolerance
impotence
thrombocytopenia
photosensitive rash
agranulocytosis
pancreatitis
88
Q

what are the side effects of sulfonylureas?

A

diarrhoea
nausea
abdominal pain
hypoglycaemia

89
Q

what are the side effects of metformin?

A 
nausea
vomiting
constipation
B12 deficiency
lactic acidosis
90
Q

what are the side effects of PPIs?

A 
diarrhoea
nausea
vomiting
hyponatraemia
hypomagnesaemia

Clinical Practice (14 decks)

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