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Emergency Medicine > TOX > Flashcards

TOX Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

When should poisoning be on the ddx

A
  • Patient with ALOC – no obvious cause
  • Inexplicable vital signs
  • Inexplicable lab tests, EKG
  • Symptoms look like a toxidrome
  • Multiple patients w/ same sx’s
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2
Q

focused Hx with poisoning should focus on

A 
Known, suspected or reported ingestion/exposure?
1.	Anticipate: What class of substance was ingested? What does it (they) do?
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3
Q

mngmt of poisoning should involve

A

v. REVERSE with antidote, if possible
vi. REMOVE residual poison, if possible
vii. NEUTRALIZE circulating poison
viii. ENHANCE ELIMINATION of the poison

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4
Q

poison control number

A

1-800-411-8080

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5
Q

initial mangement of tox pt

A

ii. Breathing - O2 Sat, RR – effectively ventilating?
iii. Circulation – BP low or high?
iv. Cardiac rhythm? Tachy? Brady? Wide or narrow? Is it changing?
v. D & E is for Disability/Decontamination/Exposure

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6
Q

why is considering who called 911 important

A

did the person who ingested this want to be saved

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7
Q

other important hx question

A 
when was it taken 
why
etoh or alcohol 
PMH
has this ever happened before
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8
Q

physical exam

A

i. Vital signs
ii. Cardiac rhythm – do they have a dysrhythmia?
iii. Level of consciousness, gag reflex
iv. Pupils - size and reactivity
v. Skin signs – sweaty, dry, hot, rash, track marks
vi. Bowel sounds – hyper-, hypoactive, are they present at all?
vii. Bladder distention
viii. Breath/body odor
ix. Evidence of trauma, focal

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9
Q

bowel sounds

A

toxidrome predictable of medicines

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10
Q

management of tox

A 
•	D-stick, EKG, Upreg right away
•	IV access, monitor, O2
•	Acetaminophen (APAP) level
•	Chem, CBC, UA, Blood 
          EtOH, Utox
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11
Q

why do you want to get a cmp

A

anion gap, electrolytes, renal, LFT’s),

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12
Q

get drug levels

A
  • Digoxin
  • Dilantin (ataxia; OD of Dilantin will make you not able to walk; they have a broad based ataxia like “drunk walking”), Carbamazepine, Valproic Acid
  • Lithium

“Comprehensive” drug screens not helpful – take too long

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13
Q

• “Coma Cocktail”

A
  • 50 cc of 50% glucose IV: (“Amp of D50”)

* Naloxone (Narcan®

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14
Q

• Naloxone (Narcan®)

A

reverses an opioid OD immediately. Narcan lasts about 45 mins. So if their OD is with a longer acting agent then they will come back for the 45 mins, the narcan wears off and they will go down again. Put soft restraints b/c they will wake up UNHAPPY, combative, and irritable

• 0.8-2 mg IN, IM, IV

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15
Q

when would you get a KUB

A

• KUB for select, ingested radiopaque substances

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16
Q

special labs you may need to order

A
  • Calcium, Magnesium
  • Total CK (rhabdomyolysis)
  • PT/INR (hepatotoxic, coumadin)
  • Serum osmolarity/osmolar gap
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17
Q

methods of removal

A

decontamination
• HAZMAT, protection for HCP
• Forced emesis**
• Surgical removal

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18
Q

Forced emesis**

A

b/c concerned about airway complications and esophageal rupture so don’t use this method

Rare: no syrup of ipecac

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19
Q

how do you neutralize

A 
•	1 gm / kg administered orally
•	Repeat dosing for some drugs
•	Give with cathartic (Sorbitol)
•	Can be given pre-hospital
•	Not always useful, can be dangerous
Antidote: known ingestion/exposure
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20
Q

ENHANCE ELIMINATIONhis look like and what do we use

A
  • Whole bowel irrigation
    * Go-Lytely
  • Dialysis, Hemofiltration
  • Enhance urinary excretion

usually reserved for people who have ingested packets of drugs

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21
Q

i. Opiates tx

A

naloxone

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22
Q

ii. Acetaminophen tx

A

– N-acetylcysteine

1. NAC, Mucomyst

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23
Q

iii. Digoxin

A

– Digibind Fab-fragments

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24
Q

iv. Benzos -

A

flumazenil

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25
Q

v. Cyanide

A
  • Lilly kit
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26
Q

vi. INH –

A

– pyridoxine

B6?

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27
Q

Carbon Monoxide

A

vii. Carbon Monoxide – oxygen

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28
Q

• Anticholinergics -

A

physostigmine

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29
Q

• Cholinergics

A

atropine, 2-PAM

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30
Q

• Beta blockers

A

glucagon (increases force and rate of contraction – chronotropic and ionotropic)

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31
Q

Ca channel blockers - TX

A

calcium

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32
Q

TricyclicsTX

A

Na bicarbonate

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33
Q

• Metals -TX

A

chelating agents

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34
Q

• Iron TX

A

deferoximine

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35
Q

• Warfarin (Coumadin TX

A

): Vitamin K
• Over-anticoagulation common
• Hold dose, check bleeding

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36
Q

Causes of osmolar gap

A
  1. Methanol
  2. Ethylene glycol
  3. Ethanol
  4. Isopropyl alcohol
  5. Others….
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37
Q

normal anion gap

A

Calculated

1. Normal = <10

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38
Q

AG calculation

A

Na) – (Chloride + TCO2); Normal 5-15

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39
Q

Things that show up on a plane film

A
  • Chloral hydrate
  • Heavy metals
  • Iron
  • Phenothiazines; Packets of drugs (body packers)
  • Enteric coated pills
  • Salicylates
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40
Q

charcoal does not work on these

A
  • Iron
  • Lithium
  • Cyanide
  • Pesticides
  • Acids and alkalis
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41
Q

why would you give someone charcoal in a NG tube

A

losing airway is not good with this

black slurry

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42
Q

what are toxidromes

A

predictable effects of particular medication

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43
Q

Anticholinergic toxidrome

A

a. Mad as a hatter
b. Blind as a bat
c. Red as a beet
d. Dry as a bone
e. Hot as hell

  1. Flushed, dry skin
  2. Elevated temp, pulse
  3. Agitated delirium
  4. Hallucinations
  5. Dilated pupils
  6. Seizures
  7. ABSENT BOWEL SOUNDS
  8. Distended bladder
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44
Q

what medications cause anticholinergic SE

A 
Benadryl 
scopolamine 
atropine
TCA
carbamazepine
flexaril (muscle relaxer)
plants
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45
Q

plants that cause anticholinergic SE

A

Jimson Weed, Belladonna

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46
Q

support for anticholinergic

A

a. Supportive: IV fluids, monitor
b. Charcoal, Benzo’s
c. Don’t sedate with antipsychoticà enhances anticholinergic effectà seizure, sicker
d. Critical? Physostigmine

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47
Q

Cholinergic toxidrome

A

SLUDGE

i. Salivation
ii. Lacrimation
iii. Urination
iv. Diaphoresis
v. GI upset
vi. Emesis

b. Bradycardia ,Wheezing
c. Constricted pupils (pinpoint)
d. Lethargy

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48
Q

what can cause a toxidrome

A
  • Pesticides
    * Organophosphates
  • Chemical Warfare agents
    * Sarin, VX, etc
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49
Q

Tx fro cholinergic toxidrome

A
  • Decontamination, supportive
  • Atropine – muscarinic effects
  • Pralidoxime (2-PAM) – both muscarinic and nicotinic effects
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50
Q

Cholinergic tx

A
  • Decontamination, supportive
  • Atropine – muscarinic effects
  • Pralidoxime (2-PAM) – both muscarinic and nicotinic effects
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51
Q

sympathomemetic toxidrome

A

GO SPEED RACER

  • Elevated BP, pulse, temp
  • Can be really high
  • Agitated delirium
  • Seizures
  • Dilated pupils
  • Normal skin or sweating
  • normal bowel sounds
  • Bladder not distended
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52
Q

sympathomemetic drugs

A
  • Cocaine, Amphetamines, Ecstasy
  • Multiple formulations
  • Caffeine
  • Pseudoephedrine, Ma Huang (ephedra)
  • Ritalin, Adderall, diet pills
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53
Q

sympathomemtic vs anticholinergic

A

NORMAL BOWEL SOUNDS

BLADDER NOT DISTENDED

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54
Q

sympathomemtic tx

A

a. IV fluids, Benzo’s, cooling
b. Control VS
c. Charcoal, Go-Lytely if ingested packets

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55
Q

classic triad of opiate toxidrome and 2 others

A
  • Depressed LOC
    * Lethargy to coma
  • Decreased respirations (4)
  • Pinpoint pupils (miosis)
  • Hypotension
  • Pulmonary edema
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56
Q

opiates that cause sxs

A
  • Heroin, methadone
  • Morphine, Dilaudid, Meperidine (Demerol)
  • Fentanyl - patches
  • Codeine, Hydrocodone, Oxycodone
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57
Q

special opiates

A
  • Lomotil

* Dextromethorphan

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58
Q

v. Serotonergic (Serotonin Syndrome) usually happens as a result of

A

• Most common w/ dose increase, addition of another to tx or overdose

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59
Q

Serotonergic toxidrome

A
  • Agitated or comatose
  • Elevated temperature, pulse
  • Hypo- or hypertension
  • Normal pupils
  • Normal skin signs
  • Increased reflexes
  • Clonus -hold it and bounce
  • “Wet dog” shakes
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60
Q

Serotonergic meds

A
  • SSRI’s, SSNRI’s, MAOI’s
  • SSRI’s + triptans
  • Combo with pain meds
61
Q

Serotonergic treatment

A

a. Withdraw offender, supportive

b. Benzo’s

62
Q

Doesn’t fit a toxidrome? consider

A

i. Mixed ingestion/exposure
ii. Head trauma
iii. Infection
iv. Shock
v. Metabolic imbalance

** meningitis is possible

63
Q

i. Common, silent, deadly: order level in ALL poisoned pt’s.

A

h. Acetaminophen

64
Q

what levels are toxic for acetaminophem

A

7.5g in adults or 150mg/kg in kids is toxic

Timing of ingestion is key – 2-4hr first level

65
Q

what is the APAP key

A

timing of ingestion is key – 2-4hr first level

66
Q

what are sxs of apap

A

iv. Typically few sx’s first 24hrs

v. Then: RUQ abd pain, malaise, nausea

67
Q

labs for APAP ingestion

A

ASA, CBC, Chem, UA, Upreg, EKG

ix. Serial levels every 4-6hrs depending on Hx

68
Q

Treatment for APAP

A
  1. Charcoal if recent

2. N-acetylcysteine (NAC, Mucomyst) for 72hrs

69
Q

Aspirin – Salicylates

A

i. Common, acute or chronic – slowed absorption, concretions

70
Q

Early/mild sx’s ASA

A

Early/mild sx’s: tachycardia, tinnitus, n/v, abd pain, tachypnea, diaphoresis

71
Q

Late/severe ASA sxs

A

Late/severe: coma, seziures, resp depression, non-cardiogenic pulmonary edema, dehydration, shock

72
Q

how does chronic ASA tox occur

A

concretions

big ball of ASA hard to break up

73
Q

severity of the ASA toxicity is directly related to the

A

iv. Severity = acid base imbalance

74
Q
  1. Mild toxicity/first sign
A

alkalosis

75
Q
  1. Progression
A

: resp alkalosis and AG metabolic acidosis

76
Q
  1. Severe/progression
A

severe AG metabolic acidosis

77
Q

labs for ASA

A

v. Labs: ASA, APAP, UA/Upreg, CBC, Chem, ABG, EKG, serial ASA levels

78
Q

TX for ASA

A

ABC’s, IV hydration, charcoal w/o cathartic, alkalinize urine (bicarb)

79
Q

Pt with persistent, inexplicable tachycardia?

A

vii. Pt with persistent, inexplicable tachycardia? Think aspirin

80
Q

what amount of NSAIDS is toxic

A

ii. 100mg/kg usually benign; co-ingestion

>400mg/kg may be life-threatening

81
Q

NSAIDS >400mg/kgsxs

A
  1. ALOC/coma, acidosis, seizures, pulmonary edema
82
Q

k. Oral Hypoglycemics/Insulin sxs

A

i. Sx’s: ALOC, diaphoresis, tachycardia, bizarre behavior, paralysis, seizure – can mimic CVA

83
Q

immediate dx with altered pts

A

ii. Immediate d-stick on ALL altered patients

84
Q

sulfonyureas reversal

A

Sulfonylureas, Insulin – rapid reversal with 1 amp D50 after d-stick

85
Q

iv. Metformin overdose

A

less profound hypoglycemia but lactic acidosis w/ AG present

86
Q

The problem with oral hypoglycemics:

A
  1. They last a long time, longer than 1 amp D50
  2. Pt becomes repeatedly hypoglycemic
  3. Admit these folks with glucose rich IV drips
87
Q

Insulin OD

A

– admit if severe. Can correct, watch for 6hrsàhome if stable, no risks, not suicide

vii. Feed everyone with hypoglycemic toxicity

88
Q

amitriptyline

Nortriptyline

A

TCA

89
Q

amitriptyline

Nortriptyline TCAs toxidrome

A

iii. Anticholinergic toxidrome

90
Q

ECG chnages with anticholinergics

A
  1. First – sinus tach
  2. Terminal R-wave in aVR
  3. Widened QRS
  4. Ventricular tachycardia
91
Q

other than an anticholinergic and EKG changes what other sxs do you see

A

v. Coma, seizures, hypotension

92
Q

what is the reversal agent

A

vi. Charcoal, whole bowel irrigation

93
Q

sxs of iron overdose

A

ii. Nausea, vomiting, abd pain, diarrhea

94
Q

sith suspected iron overdose need to figure out

A

iii. Estimate amount and which prep

95
Q

sxs of iron overdose

A
  1. AG metabolic acidosis
  2. WBC’s >15k
  3. Glucose >150
  4. Serum iron test
96
Q

what dx tests for suspected iron

A

KUB good – Charcoal does not work

97
Q

vin rose

A

Dexferoxamime

antidote for iron

98
Q

sxs of digoxin

A
  1. N/V/D, bradyarrhythmias, hyperkalemia, CNS sx’s, EKG with specific findings
  2. Dig level, Digibind Fab if arrhythmias
99
Q

BB overdose sxs

A
  1. Brady, hypotensive, ALOC, ventricular arrhythmias
100
Q

labs for suspected digoxin overdose

A
  1. Dig level, Digibind Fab if arrhythmias
101
Q

BB overdose treatments

A
  1. IV fluids, tx shock, charcoal if indicated
102
Q

CCB tx

A
  1. Sx’s/Tx much like Beta Blockers – add Calcium
103
Q

read flags with alcohol overdose

A
  1. EtOH level does not match sx’s
  2. Not “metabolizing” (getting less drunk) with time
  3. Trauma – do a good exam
  4. GI bleeding, abd pain, n/v
  5. Confusion, can’t walk
  6. Jaundice, bruising
104
Q

can’t wait for chronic ETOH to get to 0

A

No need for zero level to d/c! Chronic etoh’ers will experience withdrawal sx’s at zero!

105
Q

Refer for alcohol Tx

A

Benzo’s Rx for mild withdrawal sx’s

106
Q

PE Signs:

A
  • Tongue wag (fasiculations in the tongue), tremor
  • Tachycardia
  • Low grade temp
107
Q

Red Flags fir alcohol withdraw

A
  • Hallucinations, confusion
  • Agitated delirium
  • Seizure, asterixis
  • Jaundice
108
Q

tx for alcohol withdra

A

IV fluids, monitor, EKG, high vis bed
• Give thiamine IV
FEED THEM

109
Q

LABS for alcohol withdraw

A

• Labs: CBC, Chem, PT/INR, Magnesium, Phosphorus

110
Q

rx for alcohol withdrawal

A
  • Benzo’s: Lorazepam 2-4mg IV until sx’s abate or need an airway
  • Phenobarbital helps avoid Sz – long acting – give early
  • IV 130-260mg q 30min until sedation or 1040mg
111
Q

early sxs of mushrooms

A

iv. Early GI symptoms (w/in 2hrs) usually reassuring

112
Q

delayed sxs of mushrooms

A

Delayed symptoms (>6hrs) associated with liver, kidney, CNS damage

113
Q

labs for mushrooms

A

LFTSvi. Get LFT’s, coags, electrolytes, monitor closely

114
Q

return to this slide

mushroom tx

A

. Amanita phalloides: delayed liver failure (day 3)

  1. Amanita Smithiana: delayed renal failure (day 3)
  2. Lepiota: delayed liver failure (day 3)

vii. Call Poison Control for ALL mushroom toxicity

115
Q

onset of Rohypnol (flunitrazepam)

A
  1. Rohypnol (flunitrazepam): pill form, illegal in U.S.
    a. Sedation, muscle relaxation, amnesia
    b. 15-30min onset, lasts 4-6hrs; tablets now dissolve with blue color
116
Q

GHB (gamma-hydroxybutyric acid onset

A
  1. 15min onset, lasts 3-4hrs, gone from body in 8hrs

2. Sedation, amnesia

117
Q

ketamine

A

liquid/powder, onset in minutes, lasts up to 4hrs

1. Psychoactive, muscle paralysis, amnesia

118
Q

OTC sedation

A
  1. Visine (tetrahydrozoline), Afrin (oxymetazoline), others
119
Q

peak ingestion of one pill kill

A

i. Peak age of ingestion is 1-3yr olds

120
Q

one pill kill list

A
  1. BIG ONE Calcium Channel Blockers – shock, brady arrhythmias
  2. Clonidine – opiate toxidrome
  3. Lomotil – opiate toxidrome
  4. Sulfonylureas – hypoglycemia, seizures, coma
  5. Cyclic Antidepressants – anticholinergic, dysrhythmias
  6. Salicylates – same sx’s as adults – more serious
121
Q

hypoglycemia, seizures, coma in children

A

sulfonylureas

122
Q

pepto bismol

oil of wintergreen

A
  1. Salicylates
123
Q

Clonidine toxidrome

A

opiate toxidrome

124
Q

Lomotil toxidrome

A

opiate toxidrome

125
Q

carbon monozide poisoning seen most commonly

A

i. Common in winter months, cold climates – multiple sources

126
Q

two major contributors to smoke inhalation deaths

A

ii. Major contributor to smoke inhalation deaths (cyanide too)

127
Q

pathophys of CO poisoning

A

iv. CO binds to hemoglobin 200 times better than oxygen
1. Also binds to myoglobin, cytochromes P450 and AA3
v. Organs needing high O2 – brain, heart – affected

128
Q

labs for CO poisoning

A

vii. Lab: carboxyhemoglobin (mild <20%, severe >40%)

1. Labs, lactic acid, ABG, EKG, troponin/myoglobin

129
Q

tx for CO poisoning

A

viii. Tx: 100% Oxygen by non-rebreathing mask

1. Severe poisonings – hyperbaric oxygen chamber

130
Q

near drowning

A

inhaling water

131
Q

pathophysiology of near drowning

A

water causes loss of surfactant
Water swallowed, aspirated, alveolar flooding/loss of surfactant, hypoxia, lose airway reflexes, bradycardia, cardiac arrest, global CNS damage

132
Q

better survival with cold water or warm water

A

cold better than warm

133
Q

important questions for near drowning

A

a. Predisposing event: trauma, EtOH, hypoglycemia, seizure, MI, suicidal ideation, accidental
b. Clean or dirty water? Dove from height? Scuba diving?

134
Q

labs for near drowning

A

ii. ABC’s first, CXR, +/- Head, C-spine CT, labs, CK, ABG

135
Q

core temp <40.5 C (104.9) with normal mental status

A
  1. Heat exhaustion

Normal mental status, dehydrated, sweating, weak, n/v, HA

136
Q

heat stroke sxs

A

va. ALOC, ataxia, dry/hot/flushed skin, +/- sweating

b. CNS, coagulation, liver, renal damage

137
Q

heat stroke temp

A

core temp >40.5 C – life threatening

138
Q
  1. Drugs associated with increased heat production
A

a. Cocaine, amphetamines, EtOH, salicylates

139
Q

what do you search for with increased temp

what’s tx

A

a. D-stick, CBC, CMP, PT/INR, CK, TSH, UA, Upreg/tox

b. Tx: ABCDE’s, cooling (ice packs, fan/wet sheet), Tylenol or NSAIDS do not work here

140
Q
  1. Malignant hyperthermia
A

rare, genetic, precipitated by anesthesia drugs: muscle rigidity, rhabdo

141
Q

osborne waves are associated with hypo or hyperthermia

A

hypo

142
Q

primary hypothermia

A

exposure, EtOH, elderly, infants, immersion

143
Q

Secondary hypothermia

A

Sepsis, trauma, CVA, endocrine

144
Q
  1. Iatrogenic hypothermia
A

: IV fluids not warmed, ambient temp

145
Q

kids: mammalian diving reflex

A

iv. Metabolism slows – kids: mammalian diving reflex

146
Q

multi systems involved in hypotension

A
  1. Cardiac – gentle handling to avoid dysrhythmias
    a. Tach Brady, Osborn wave on EKG
  2. CNS – clumsy, confusion, shivering
147
Q

tx for hypotension

A

remove/tx cause, d-stick, EKG, upreg, warm IV fluids and O2, Bear-Hugger rewarming pad, feed

148
Q

i. Snake bites**

A

none proven – immobilize/transport best

a. Keep the pt still

Emergency Medicine (28 decks)

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