Tox

Question 1

Anti-Cholinergic

Answer 1

Sx - tachy, dry mm, red face, delirious, hallucinations, mumbled speech (ask to recite ABCs), picking, dilated pupils

Source - jimson weed, TCAs, anti-histamines, Flexeril, atropine, anti-psychotics

Tx - BENZOS

Question 2

Opioids

Answer 2

Sx - CPR (coma / pinpoint pupils / dec RR)

Tx - naloxone .04-.4 mg IV q 1-3 min (until adequate respirations NOT until awake)

Question 3

Sympathomimetics

Answer 3

Sx - agitated, dilated pupils, tachy, seizures, psychosis, elevated temp

Work-up - check temp, EKG, CPK, CT head (high risk self-harm)

Tx - BENZOS (do not give beta blockers - unopposed alpha)

Question 4

Cholinergic

Answer 4

SLUDGE - salivation, lacrimation, urination, defecation, GI distress, emesis

Killer B’s - bronchorrhea, bronchospasm, bradycardia

Tx - atropine 1 mg q 2-5 min (until improvement in killer B’s)

Sources - organophosphate pesticides, nicotine

Question 5

Sedative or Alcohol Withdrawal

Answer 5

1 - tremor, tachy, diaphoresis, HTN (~6 hrs)

2 - Sz (short and generalized) SHOULD NOT BE FOCAL

3 - hallucinations (tactile or visual, rarely auditory)

4 - Delirium Tremens (waxing and waning agitated delirium, diaphoresis and autonomic dysfunction) (~72 hrs)

RF - personal or family hx of withdrawal, normal neuro exam at high alcohol level

Question 6

Basic Principles of GI Decontamination

Answer 6

• If < 1 hr since ingestion of potentially dangerous material and the patient is fully ALERT (no aspiration risk) then can give activated charcoal
• Whole bowel irrigation mainly used for iron (2L miralax per hr via NG)

Question 7

Basic Tox Work-Up

Answer 7

CMP, CPK, UA, VBG

EKG (look at QRS duration and QT prolongation)

Ethanol / APAP / salicylate levels

Basic Urine Drug Screen

Question 8

Basic Urine Drug Screen (what is it good/bad for?)

Answer 8

Good for … diazepam, morphine/heroine (natural opiates), amphetamine, cocaine, PCP

Bad for … lorazepam, oxy / synthetic opioids

False Positives … dextromethorphan, pseudoephedrine, phenylephrine, buproprion, ketamine

Question 9

Tylenol OD

Answer 9

8 - 12 hrs - asymptomatic or N&V
12-36 hrs - early inc AST
72-96 hrs - max hepatotoxicity
> 96 hrs - resolution / death / transplant

Rumack-Matthew nomogram based on 4+ hr level

Work-Up: APAP level, salicylate /ethanol (co-ingestions?), CMP, INR, EKG

Question 10

NAC (indications and dosing)

Answer 10

Indications - above level on nomogram OR APAP > 10 in chronic OD (>24 hrs) OR elevated ALT/AST in chronic OD (> 24 hrs)

150 mg/kg over 1 hr
50 mg/kg over 4 hrs
100 mg / kg over 16 hrs

**continue until labs improve, transplant or death

Question 11

King’s College Criteria

Answer 11

Transplant in APAP OD:

pH < 7.3 after IVF resuscitation

OR

PT > 100 (INR > 6)
+ Cr > or = 3.4
+ grade III or IV encephalopathy

Question 12

ASA OD

Answer 12

Mech: uncouple oxidative phosphorylation –> met acidosis, heat, dec ATP, inhib Kreb’s so hypoglycemia

Sx: tachypnea, tachycardia, N&V, tinnitus, AMS, sz, inc temp

Work-Up: VBG (mixed resp alk and met acid), CMP, glucose, SERIAL SALICYLATE LEVEL q 2-3 hrs (slow absorption)

Tx: IVF (LR), sodium bicarb to trap salicylic acid in ionized form so cannot cross membranes (goal pH = 7.5 -7.55), dialysis (if AMS, renal dx, seizure, pulmonary edema, or level > 100)

Question 13

Serotonin Syndrome

Answer 13

Sx: autonomic instability, lower extremity clonus

Tx: stop offending agent, benzos, cooling

Question 14

Bupropion Toxicity

Answer 14

Structurally similar to amphetamines –> seizures

Cardiotoxic –> inc QRS

Question 15

TCA Toxicity

Answer 15

Anti-cholinergic

Na and K channel blockade –> QRS inc and QT prolongations

Seizures

Hypotension

Question 16

Lithium Toxicity

Answer 16

Sx: acute GI sx, chronic tremor and ataxia

Tx: IVF, HD

Question 17

Neuroleptic Malignant Syndrome

Answer 17

Sx: autonomic instability, dec reflexes, diffuse lead pip rigidity

Sources: dopamine antagonists (anti-psychotics) or withdrawal from dopamine agonists (carbidopa-levodopa)

Tx: stop offending agent, cooling, IVF

Check CPK, consider paralysis if rhabdo

Question 18

Carbamazepine Toxicity

Answer 18

anti-cholinergic

Question 19

Valproic Acid Toxicity

Answer 19

metabolic acidosis and hyper-ammonia