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Pharm II exam 1 > Tox II > Flashcards

Tox II Flashcards

1
Q

Effects of cocaine…

T or F. Smoked cocaine rapidly crosses alveoli and BBB.

A

Sympathomimetic - stimulates A1, A2, B1, B2. - tachy, urinary retention, sweaty, sedation, halted peristalsis
T

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2
Q

Manifestations of cocaine. 4.

A

CVA, brain bleeds
seizures
chest pain
rhabdomyolysis

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3
Q

How to manage a cocaine OD -

Anxiety/psychosis, HTN, Rhabdo

A
  1. Anxiety/psychosis - Diazepam (BZD), haloperidol
  2. HTN - labetalol (alpha blockade)
  3. Rhabdo - bicarb to alkalinize the urine
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4
Q

Why does cocaine cause rhabdo?

A

vasoconstriction - cuts off o2 supply to muscles

increased muscle activity

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5
Q

Explain the mechanism of carbon monoxide poisoning.

A

When inhaled, CO binds to Hgb to form carboxyhemoglobin. O2 can no longer bind to Hgb. Body reverts to anaerobic metabolism –> LA builds up –> proteins denature…

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6
Q

All patients with suspected CO poisoning should be placed on ………..If depressed consciousness….

A

Supplemental high flow 100% O2.

Hyperbaric O2.

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7
Q

TCA tox pneumonic - T-C-A

A

T - tonic clonic seizures
C - Cardiac - dysrhythmia, conduction disturbance, Inh Na+
A - Anticholinergic - tachy, HTN, drying, constipation

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8
Q

2 drugs that are NOT TCAs but we treat them in the same way as a TCA in overdose

A

Cyclobenzaprine

CBZ

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9
Q

What is the hallmark of TCA OD?

What is the antidote to TCA OD?

A

Widened QRS

Bicarb`- protects myocardium - shrink QRS

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10
Q

What drug is contraindicated in TCA OD? It seems logical, but in reality it does not work.

A

Physostigmine - AChesterase inhibitors (increase ACh) to reverse anti-cholinergic effects of TCA.

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11
Q

If a patient ingested TCA + Benzo, does it make sense to give them Flumazenil (benzo antidote)?

A

NO - because benzo actually treats the seizure component of TCA OD.

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12
Q

Classic triad of opioid intox.

A
  1. Miosis
  2. Respiratory Dep
  3. Depressed LOC
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13
Q

Naloxone primary action is to………
What is the best route?
What about ET tube?

A

Reverse the respiratory depression
IV
ET tube - double dose

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14
Q

> 2mg of Naloxone is required for what drugs?

A
  1. Pentazocine
  2. Codeine
  3. Methadone - difficult to reverse
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15
Q

Why do you need to continually infuse Naloxone?

A

it has a short half life

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16
Q

Regimen of nalaxone:

A

12 mg initially, then 8mg an hour as continuous infusion

2/3 of initial dose

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17
Q

T or F. Naloxone is relatively non-toxic.

A

T.

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18
Q

What is the biggest con to giving a narc addict Naloxone?

A

It will induce withdrawal - irritability, N/V, tachycardia, tremor, lower sz headache

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19
Q

Beta blocker OD manifests as….

Treatment is oriented at reversing….

A

bradycardia

depression of inotropy…reverse this

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20
Q

What is the DOC for increasing inotropy? What may be required?

A

Glucagon - (independent of beta receptors) follow with insulin

  • pacing
  • atropine - anticholinergic (sympathetic stimulation)
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21
Q

T or F. Hydrocarbons are relatively non-toxic.

When should you take someone to the ED for OD?

A

T.

When burping, coughing, throwing up - fear of aspiration -> aspiration PNA with anaerobes (Clindamycin)

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22
Q

What is the hallmark sign of Phencyclidine (PCP) toxicity? What should you do?

A

Violent or bizarre behavior

Put in holding room.

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23
Q

Organophosphates/Pesticides are __________ for humans.

A

Nerve gases

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24
Q

What is the MOA for organophosphate OD?

A

Irreversibly inhibit AChesterase. If you inhibit this enzyme, you get a BIG increase of ACh.
Bradycardia, wet, diarrhea, pee themselves

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25
Q

What is a weird characteristic of nerve gas tox?

A

Garlic-like odor

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26
Q

What 3 systems are affected by the nerve gas tox?

A
  1. Cholinergic (Parasympathetic NS) - SLUDGE
  2. Nicotinic - muscle weakness
  3. CNS - confusion, slurred speech, respiratory depression
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27
Q

What is the treatment for organophosphate tox?

A
  1. Remove clothes, decontamination with copious flushing with COLD water.
  2. Atropine for symptom management
  3. Pralidoxime (2-PAM)
28
Q

What is Pralidoxime?

A

ACHesterase RE-ACTIVATING agent
Works within 10-40 mins
Best used within 24h

29
Q

Barbituate toxicity MOA -

Describe a barb tox.

A

CNS inhibition by potentiating GABA

Respiratory depression, hypotension, decreased LOC, slurred speech, coma, appear “dead”

30
Q

What drug is used for euthanasia? What would be the most “ideal” agent for committing suicide?

A

Barbituates

Ultra-short acting (quick on) -Thiopental

31
Q

What is the standard therapy for barb OD?

A

supportive care and GI elimination

32
Q

What additional therapy is necessary for a Phenobarbital OD?

A

Bicarb so that you can alkalinize the urine (“trapping ions” in the kidneys”.
Phenobarb is very acidic.

33
Q

What are the 3 drugs for lethal injection?

A
  1. Thiopental
  2. NMB
  3. KCl
34
Q

T or F. Benzos are very dangerous in OD.

A

F - death is rare from benzos alone. They ARE dangerous when combined with EtOH or other CNS depressants

35
Q

Name a benzo. How do they work? What is the clinical presentation?
Are they expensive or cheap on the street?

A

Clonazepam/Xanax - enhance GABA
Lethargy, slurred speech, ataxia, respiratory depression, coma.
Cheap $3.

36
Q

T or F. Giving ipecac for a Midazolam (ultra-short acting) OD is a good idea. You should not use activated charcoal.

A

F. Do not induce emesis due to rapid progression to come (fear of aspiration)
Use charcoal.

37
Q

When is it appropriate to reverse benzo OD using Flumazenil? What are the 2 CONTRAindications?

A

When the patient has ONLY taken benzos

Sz history, TCA OD

38
Q

EtOH - (Alcohol dehydrogenase) - ________ - (Aldehyde dehydrogenase) - CO2, H2O
MeTOH - (AD) - ___________ - (AD) - _____________.
Ethylene Glycol - (AD) - ___________ - (AD) - __________.

A

Aceta aldehyde.
Formaldehyde - Formic Acid
Glyco Aldehyde - Glycolic Acid

39
Q

Name a Aldehyde dehydrogenase inhibitor.

A

Metronidazole

Causes Disulfiram rxn - antebuse

40
Q

Name an alcohol dehydrogenase inhibitor.

A

Chlorahydrate - Mickey Finn Drug

41
Q

If you took all 3 substances - EtOH, MetOH, Ethylene Glycol - which substance would alcohol deh perfer to bind to?
What does this mean for methanol and ethylene glycol intoxications?
Con for giving alcohol?

A

Ethanol
Give alcohol as antidote for MetOH or Ethylene glycol tox. It will tie the enzyme up so that it cannot help the other two substance break down into the toxic metabolites.
Inebriation.

42
Q

Is methanol toxic in itself?

A

No - the metabolites are

Formic acid - vision disturbances from optic nerve damage

43
Q

Is Ethylene glycol toxic by itself?

A

No
Glycolic acid -> Glycooxylic acid -> oxalic acid = metabolic acidosis and Calcium oxalate crystals - > acute renal failure in hours

44
Q

Instead of giving alcohol, is there another drug you can give to those who OD on methanol/ethylene glycol? Con?

A

4-Methylpyrazole (4-MP)/ Fomepizole - inhibits alcohol dehydrogenase (like Chlorahydrate)
no inebriation
$$$

45
Q

For SEVERE cases of methanol poisoning, what else can you do for the patient in addition to 4-mp or alcohol?

A

Hemodialysis.

46
Q

Describe ethylene glycol.

A

Colorless, odorless, sweet-tasting, water soluble liquid (Dogs like it).

47
Q

what would chlora hydrate do to ethylene glycol toxicity?

A

Decrease it, because it inhibits alcohol dehydrogenase. and the metabolites cannot be formed.

48
Q

What would metronidazole do to methanol toxicity?

A

Decrease it, because it inhibits Aldehyde dehydrogenase, The metabolites will not formed.

49
Q

All alcohols are removed by dialysis. What happens when you send someone to dialysis who is being treated by an antidote?

A

Be aware that hemodialysis removes toxin AND antidote. So you may need to give additional antidote (ethanol, Fomeprizole).

50
Q

What happens when you’re drinking Makers Mark and you’re given Fomeprizole?

A

Inebriation.

It inhibits alcohol dehydrogenase and will increase serum alcohol levels.

51
Q

If you see patient seen down, OD, with calcium oxylate crystals in urine, what is the expected OD from?

A

Ethylene glycol

52
Q

T or F. Isopropyl alcohol is highly toxic.

what does it irritate?

A

F. Only toxic at high levels

Stomach.

53
Q

Isopropyl alchohol - Alc de - __________, which is a ________, that causes what funny clinical finding?

A

acetone
ketone
fruity smell on breath (like DKA)

54
Q

Treatment for isopropyl alcohol/ethanol OD?

A

Supportive, no emesis
Gastric lavage w/i 2 hours of ingestion
Severe - hemodialysis

55
Q

T or F. Activated charcoal is a reasonable antidote for isopropyl alcohol or ethanol.

A

FALSE

AC does not bind alcohols.

56
Q

What are 2 additional things you should replace for someone who has ethanol intoxication.

A

Glucose

thiamine

57
Q

APAP -> conjugated (95%) to _________ in the liver. The other 5% is broken down by ________ to a TOXIC metabolite. The toxic metabolite is inactivated by conjugation w/ __________.

A

APAP-C
CP-450
Glutathione

58
Q

What happens when someone takes too much APAP?

A

Shunting towards CP 450 pathway, leading to accumulation of toxic metabolite as glutathione becomes DEPLETED.
Metabolite is directly hepatotoxic.

59
Q

There are __ phases of APA toxicity. Describe them.

A

4 phases

  1. 1 day- GI upset
  2. 2-3 days - feels better, but LFTs rise and peak at 72 hr
  3. > 3 days - hepatic dysfunction, PT/INR elevates (bc liver cannot make clotting factors), ammonia increases, hepatoencephalopathy, death
  4. 5-14 days - die or get better.
60
Q

How can you predict APAP hepatotoxicity?

A

Rummack-Matthew Nomogram

61
Q

What is the antidote to APAP? How long is it effective for?

A

N-acetylcysteine (NAC or Mucomyst)

12h post-ingestion (still used for up to 24 hours)

62
Q

How does NAC work? Con?

A

Replenishes glutathione stores in the liver.

Stinky and bad taste.

63
Q

How do you dose NAC?

A

140 mg/kg loading dose + 70mg/kg/ q4h x 17 doses

18 total

64
Q

What might you do to improve likelihood of keeping NAC down?

A

IV metoclopromide, NGT infusion…

65
Q

Should you combine NAC and charcoal? what about ipecac?

A

Charcoal - Probably not, they will bind to one another.

Ipecac - NO, they will throw up antidote.

66
Q

IV NAC is called…. what is the problem with it?

A

Acetadote - need to give LOTS of fluid and can be dangerous for children (fluid overload).

67
Q

How helpful are Tylenol levels

A

No that helpful because liver damage is slow.

Pharm II exam 1 (4 decks)

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