Tox

Question 1

Stages of Ethylene Glycol Tox

Answer 1

1) Acute Neuro Stage <12h (intoxication, cranial neuropathies)
2) Cardiopulmonary stage 12-24h (myocardial dysfunction and pulmonary edema, longQT)
3) Renal Stage 1-3d
4) Delayed Neuro sequelae (1-3w)

Question 2

Ethylene Glycol : toxic metabolite

Answer 2

Oxalic Acid
Glycolic Acid

Calcium Oxylate

Question 3

Ethylene Glycol: lab findings

Answer 3

HAGMA
Osmolar Gap
Hypocalcemia
ARF

Question 4

Ethylene Glycol: management/meds

Answer 4

□ Fomepizole 15mg/kg IV or ethanol
□ Thiamine 100mg IV; 0.25 to 0.5 mg/kg, ie 10-50mg
□ Pyroxidine 1 to 2 mg/kg
□ Calcium (e.g., 10% calcium gluconate, 0.3 to 0.6 mL/kg)
- Hemodialysis

Question 5

Methanol: metabolism and enzymes

Answer 5

Methanol (ETOH dehydrogenase) –> Formaldehyde
Formaldehyde (Aldehyde dehydrogenase) –> Formic acid
Formic acid (folate) –> CO2 and H20

Question 6

Methanol: intox clinical

Answer 6

CNS: Putamen Crisis = Leads to parkinsoniasm
Optic Neuropathy = Blindness (snowstorm vision)
GI: after latent period can see massive UGIB

Question 7

Methanol intox: labs

Answer 7

HAGMA

Question 8

Methanol intox: management/meds

Answer 8

❏ Fomepizole 15mg/kg IV or ethanol
❏ Folic acid 50mg IV (1mg/kg peds)
❏ Hemodialysis

Question 9

Acetaminophen : toxic dose

Answer 9

150mg/kg

Question 10

NAC: mechanism

Answer 10

• APAP –> NAPQI (TOXIC)
• NAC:
  ○ Precursor to glutathione (which binds NAPQI make nontoxic)
  ○ Directly binds NAPQI
  ○ Is a Glutathione substitute
  ○ Increases non toxic sulfation metabolism
  Reduces NAPQI to APAP

Question 11

APAP/Acetaminophen: tox stages

Answer 11

o Stage 1: 30 min - 24 hours  asymptomatic, or nausea, vomiting, diaphoresis, pallor
o Stage 2: 24 – 48 hours  asymptomatic OR nausea, vomiting, RUQ tenderness, with elevation of liver enzymes and jaundice
o Stage 3: 72 hours – 96 hours  fulminant hepatic failure with jaundice, thrombocytopenia, prolonged PTT, hepatic encephalopathy. Renal failure, cardiomyopathy
o Stage 4: Recovery

Question 12

ASA toxicity:
Indications for haemodialysis

Answer 12

Altered mental status,,
Renal failure
Liver failure
Pulmonary edema
Severe acidosis
Failure of urine alkalization
ASA level >3 acute and >7 chronic

Question 13

ASA toxicity
Stages

Answer 13

0 to 4 hours: respiratory alkalosis, tachypnea, tinnitus, GI
4 to 12 hours: respiratory alkalosis with acidosis, Could be normal pH, severe tachypnea, AMS: Lethargy/agitation
12 to 24 hours: Acidosis, Severe tachypnoea, delirium, pulmonary oedema, Seizure,,

Question 14

ASA toxicity:
Indications for your an alkalinization

Answer 14

ASA level >2.8
Signs of severe toxicity
Acidosis
Increasing ASA levels

Question 15

Indications of MDAC vs single dose

ABCD

Answer 15

• Antimalrrheals: Quinone, Amanita (mushroom Cyclopeptide), ASA
• Barbs: AED: phenobarb, b-blocker (some)
• Carbamazipine
• D: Dilantin,dapsone

Question 16

Activated Charcoal PHAILS at treating what?

Answer 16

• Common electrolytes
• Metals—iron, lead, arsenic, lithium
• Mineral acids or bases
• Alcohols
• Cyanide
• Most solvents
• Most water-insoluble compounds (e.g., hydrocarbons)
• Pesticides
• Hydrocarbons
• Acids/Alkali/Alcohols
• Iron
• Lithium, Lead
• Solvents

Question 17

How to calculate

OSMOLAR GAP

Answer 17

{Osmolarity} = 2Na + gluc + BUN (2 salts+ sticky + bun)

OSM GAP = Measured Osmol - {Calc Osmolarity}

(<10)

Question 18

How to calculate

ANION GAP

Answer 18

AG= Na - (Cl+Bicarb)

AG= Na- Cl- HCO3

<12

Question 19

HAGMA

causes

Answer 19

MUDPILES

• C- cyanide (lact acidosis), carbon monoxide,
• A- alcoholic ketoacidosis
• T - toluene (glue sniffing)
• M — Methanol
• U — Uremia- CKD
• D — DKA
• P — Paracetamol, Propylene glycol
• I — Infection, Iron, Isoniazid, IEM
• L — Lactic acidosis
• E — Ethylene glycol
  
  • Ethanol–> lactic acidosis, ketoacidosis
• S — Salicylates

Question 20

Toxic alcohols and

AG and OG

Answer 20

• Initial: Anion Gap HIGH
• Later: Anion gap low — Osmolar Gap HIGH
  
  • (as the alcohol is metabolized over time)

Exceptions:

• Coingestion with EtOH: Osmolar gap not high due to lack of metabolism (self-treated) – therefore delay in OG…

Question 21

Anticholinergics

• give examples
• mechanism of action of toxicity and presentation
• AntiDote

Answer 21

Examples:

• Jimson Weed
• Scopolamine. • Glycopyrrolate
• Atropine
• Benztropine (Cogentin)
• Diphenhydramine and dimenhydrinate (benadryl/Gravol)
• Olanzapin

Mechanism:

• Antagonism of muscarinic receptors
• Antagonism of central muscarinic:
  
  • delirium, agitation, or seizures
• Antagonism of peripheral muscarinic receptors:
  
  • tachycardia, decreased GI motility, urinary retention, and flushed skin

Presentation:

• Mad, Hot, Dry, tachy , mydriasis

AntiDote

• Physostigmine
  
  • Use: if no TCA
  • Dont: if TCA used, wide QRS ! or ASA allergy
  • Monitor for: bradycardia / cholinergic s/s

Question 22

Toxicity of halogenated/chlorinated HydroCarbons?

Answer 22

• Myocardial pre-sensitization:
  
  • more sensistive to Catecholamines, VTACH!
• Sudden sniffing death
  
  • Surge in NE/Epi (bec of anything straining or seizing) –> VT
• Rx:
  
  • Beta Blocker! As rx for Vtach! (only time when would come first in ACLS)

Question 23

8 groups of mushrooms - main toxicity - antidote?

Answer 23

1. Cyclopeptide - DEATH/Liver failure - NAC, pen G
   
   1. MDAC, lytes, Dialysis , liver tx
   2. (amanita phalloide)
   3. *DELAY s/s
2. Gyromitrin (brain) - Seizures - Pyridoxine (Vit B6)
   
   1. AC, benzo
3. Muscarine - SLUDGEBBB- Atropine
   
   1. ​AC
4. GI Irritant - N/V/hypovol shock- Nil
5. Coprine - Disulf like, post EtOH - Nil
6. Ibotenic Acid - CNS s/s (halluc, sz)- Nil
   
   1. amanita muscaria
7. Psyolcybin - LSD like- Nil
8. Orellinine- nephrotox - Nil
   
   1. Dialysis , lytes
   2. *DELAY s/s

Question 24

NAME 1 PILL KILLERS

Answer 24

1. TCA ( imipramine)
2. Ca channel blockers ( Verapamil, diltiazam)
3. Clonidine
4. Antimalarials ( quinine, chloroquine)
5. Sulfonylureas (glyburide)
6. Opioids (long acting?)
7. Theophylline
8. Camphor
9. B blockers( propanolol- MAYBE)
10. Diphenoxylate/atropine ( Lomotil)

Question 25

Iron tox

stages

Answer 25

• Phase 1: 0-6 hrs GI
  
  • Effects of direct mucosal injury
  • Vomiting, diarrhea, and GI blood loss
  • May lapse into early coma and shock caused by volume loss and metabolic acidosis if severe.
• Phase 2: 6-12 hrs Latent
  
  • Minimal
• Phase 3: 12-24h Multisystem
  
  • GI s/s
  • AMS: lethargy, coma, seizures
  • Metabolic acidosis
  • Renal Failure
  • CVS: shock
• Phase 4: 48h-4d Hepatic
  
  • Liver failure, transaminitis
• ​Phase 5: >4weeks Sequelae
  
  • Pyloric stenosis that results from scarring and consequent obstruction

Question 26

Iron tox

toxic dose

Answer 26

20mg/kg

Question 27

Iron tox:

• Antidote? other Rx?
• indications?
• When to stop?
• Side effects ?

Answer 27

1. Deferoxamine 15mg/kg - chelates
   
   1. WBI +/- exhange tf
2. Indications: Severe symptoms, acidosis, iron level
3. Stop: urine not pink, well, acidosis resolved, HDS
4. SEs:
   
   1. ARDS, Hypotension, hypersensitivity, Yersinia sepsis

Question 28

Naloxone

Dosing

Side Effect

Answer 28

Dosing

• 2mg (0.1mg/kg)

Side Effects:

• Opioid withdrawal
• Hypertension
• pulmonary edema
• ventricular irritability
• seizures