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Stage toxico > TN Toxicology p.1-3 > Flashcards

TN Toxicology p.1-3 Flashcards

1
Q

Name 4 principles to consider with all ingestions (4)

A
  • Resuscitation (ABCD3EFG)
  • Screening (toxidrome? clinical clues?)
  • Decrease absorption of drug
  • Increase elimination of drug
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2
Q

Name universal antidotes (4)

A

DONT

  • Dextrose
  • Oxygen
  • Naloxone
  • Thiamine (must give BEFORE dextrose)
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3
Q

Describe use and doses: Dextrose (glucose) (4)

A
  • give to any patient presenting with altered LOC
  • measure blood glucose prior to glucose administration if possible
  • adults : 0.5-1.0 g/kg (1-2mL/kg) IV of D50W
  • children: 0.25 g/kg (2-4mL/kg) IV of D25W
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4
Q

Describe use of oxygen (3)

A
  • do not deprive a hypoxic patient of oxygen no matter what the antecedent medical history (i.e.even COPD with CO2 retention)
  • if depression of hypoxic drive, intubate and ventilate
  • exception: paraquatordiquat (herbicides) inhalation or ingestion (oxygen radicals increase morbidity)
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5
Q

Describe: Naloxone (4)

A
  • central μ-receptor competitive antagonist
  • shorter t1/2 than naltrexone
  • antidote for opioids : administration is both diagnostic and therapeutic (1 min onset of action)
  • used for the undifferentiated comatose patient
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6
Q

Describe loading dose for adults: Naloxone (2)

A
  • response to naloxone can be drastic, so stepwise delivery of initial 2 mg bolus is recommended
  • draw up 2 mg to deliver IV/IM/SL/SC or via ETT (ETT dose = 2-2.5x IV dose)
    • 1st dose 0.4 mg (for a chronic opioid user, the initial dose may be much smaller)
    • if no response, deliver second dose 0.6 mg
    • if still no response, deliver remaining 1 mg
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7
Q

Describe loading dose for child: Naloxone (2)

A
  • 0.01 mg/kg initial bolus IV/IO/ETT (max 2mg per dose)
  • children over 20 kg can receive naloxone 2 mg IV
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8
Q

Describe loading maintenance dose: Naloxone (2)

A
  • may be required because half-life of naloxone (30-80 min) is much shorter than many opioids
  • hourly infusion rate at 2/3 of initial dose that allowed patient to be roused
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9
Q

Administration of naloxone can cause what in chronic users?

A

opioid withdrawal

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10
Q

Administration of naloxone can cause opioid withdrawal in chronic users. Name minor withdrawal sx (7)

A
  • lacrimation
  • rhinorrhea
  • diaphoresis
  • yawning
  • piloerection
  • HTN
  • tachycardia
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11
Q

Administration of naloxone can cause opioid withdrawal in chronic users. Name severe withdrawal sx (5)

A
  • hot and cold flashes
  • arthralgias
  • myalgias
  • N/V
  • abdominal cramps
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12
Q

Describe thiamine (Vitamine B1) (4)

A
  • 100 mg IV/IM with IV/PO glucose to all patients
  • given to prevent/treat Wernicke’s encephalopathy
  • a necessary cofactor for glucose metabolism (may worsen Wernicke’s encephalopathy if glucose given before thiamine), but do not delay glucose if thiamine unavailable
  • must assume all undifferentiated comatose patients are at risk
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13
Q

Name essential tests for toxicology (9)

A
  • CBC
  • electrolytes
  • BUN/Cr
  • glucose
  • INR/PTT
  • osmolality
  • ABGs
  • O2 sat
  • ASA, acetaminophen, EtOH levels
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14
Q

Name potentially useful tests for toxicology (10)

A
  • drug levels – this is NOT a serum drug screen
  • Ca2+
  • Mg2+
  • PO43–
  • protein
  • albumin
  • lactate
  • ketones
  • liver enzymes
  • CK
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15
Q

True or false

Negative toxicology screen does not rule out a toxic ingestion

A

True

signifies only that the specific drugs tested were not detectable in the specimen

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16
Q

Describe use of Urine drug screen in the ED management of the poisoned patient (1)

A

Urine drug screen is costly and generally not helpful in the ED management of the poisoned patient

17
Q

Name causes of increased anion gap (8)

A

“GOLDMARK” (* = toxic)

  • Glycols* (ethylene glycol, propylene glycol)
  • Oxoproline (metabolite of acetaminophen)*
  • L-lactate
  • D-lactate (acetaminophen, short bowel syndrome, propylene glycol infusions for lorazepam & phenobarbital)
  • Methanol*
  • ASA*
  • Renal failure
  • Ketoacidosis (DKA, EtOH*, starvation)
18
Q

Name causes of decreased anion gap (4)

A
  • Electrolyte imbalance (increased Na+/K+/Mg2+)
  • Hypoalbuminemia (50% fall in albumin ~5.5 mmol/L decrease in the AG)
  • Lithium, bromine elevation
  • Paraproteins (multiple myeloma)
19
Q

Name causes of increased osmolar gap (6)

A

“MAE DIE” (if it ends in “-ol”, it will likely increase the osmolar gap)

  • Methanol
  • Acetone
  • Ethanol
  • Diuretics (glycerol, mannitol, sorbitol)
  • Isopropanol
  • Ethylene glycol

Note: normal osmolar gap does not rule out toxic alcohol; only an elevated gap is helpful

20
Q

Name causes of Increased O2 saturation gap (3)

A
  • Carboxyhemoglobin
  • Methemoglobin
  • Sulfmethemoglobin
21
Q

How to calculate Anion Gap? (1)

A

= Na+ – CI– – HCO3–

Normal AG ≤12 mM/L

22
Q

Name causes of normal anion gap in metabolic acidosis (3)

A
  • Renal HCO3- loss:
    • renal tubular acidosis
    • hyperparathyroidism
  • GI HCO3- loss: diarrhea, fistula
  • Other:
    • NS infusion
    • acetazolamide
    • hyperkalemia
    • hypoaldosteronism
23
Q

Name Gastrointestinal Decontamination (5)

A
  • single dose activated charcoal
  • whole bowel irrigation (very rarely used)
  • multidose activated charcoal
  • surgical removal in extreme cases
  • use of cathartics (i.e.ipecac) and gastric lavage in the ED is not recommended
24
Q

Describe: Single dose activated charcoal (3)

A
  • use of activated charcoal is a source of much debate amongst toxicologists. Evidence of effectiveness is not strong, and risk of aspiration is high.
  • adsorption of drug/toxin to activated charcoal decreases toxin bioavailability
  • odourless, tasteless, prepared as slurry with H2O
25
Q

Name CI of single dose activated charcoal (4)

A
  • unprotected airway
  • late presentation after ingestion
  • small bowel obstruction
  • poor toxin adsorption
26
Q

Describe dose: single dose activated charcoal (1)

A

10 g/g drug ingested or 1g/kg body weight (may vary depending on ingestion)

27
Q

Describe dose of whole bowel irrigation (2)

A
  • 500 mL/h (child) to 2000 mL/h (adult) of polyethylene glycol solution by mouth until clear effluent per rectum
  • start slow (500 mL in an adult) and aim to increase rate hourly as tolerated
28
Q

Name indications: whole bowel irrigation (5)

A
  • awake, alert, can be nursed upright OR intubated and airway protected
  • delayed release product
  • drug/toxin not bound to charcoal
  • drug packages (if any evidence of breakage emergency surgery)
  • recent toxin ingestion
29
Q

Name contra-indications: whole bowel irrigation (3)

A
  • evidence of ileus
  • perforation
  • obstruction
30
Q

Multidose activated charcoal may be used for what? (4)

A
  • carbamazepine
  • phenobarbital
  • quinine
  • theophylline for toxins which undergo enterohepatic recirculation

Stage toxico (9 decks)

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