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Toxicology Flashcards

1
Q

What is the pathophysiology of PRIS

A

Propofol for longer than 48 hours
> 4mg /kg/hr
Inhibition of mitochondrial function

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2
Q

What is the presentation of PRIS

A 
Metabolic acidosis
Rhabdomyalasis
Brady arrhythmia
Increased triglycerides 
Heart failure
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3
Q

What is the management of lithium overdose

A

Whole bowel irrigation
HD
Keep sodium high as Low sodium impairs clearance

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4
Q

What are the Features of lithium poisoning ?

A 
Ataxia
Tremor
Seizures
D and V
Polyuria
Aki
Nephrogenic DI
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5
Q

What is the management of digoxin toxicity?

A

Activated charcoal if < 2 hrs
Correct low k and mg
Atropine
Digibind (each vial corrects 0.5mg digoxin)

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6
Q

How does digoxin toxicity work and what ecg changes occur?

A

Slow AV conduction
Block na - k ATPase leading to an influx of ca2+ and therefore +ve inotrope

Causing 
AV blockade
Brady 
VT
Reverse tick
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7
Q

What is the management of beta blocker and calcium Chanel antagonist Overdose ?

A 
Fluid
Atropine
Inotropes
Pacing
CaCl-
Glucagon ( increases CAMP)
HDIT

Va ECMO

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8
Q

What is the Management of Paraquat toxicity?

A

Activated charcoal
Lowest oxygen
Cyclophosphamide
Methylpred

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9
Q

What is the pharmacology of paraquat poisoning ?

A

Found in pesticides
15-20mls has 75% chance of toxicity
Breaks down endothelial lining
Pulmonary fibrosis and oedema

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10
Q

What are the features of carbon monoxide poisoning ?

A 
Confusion
Cherry red skin
Cyanosis
Levels of 40% life threatening
Levels of 60% are fatal
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11
Q

What is the Pathophysiology of carbon monoxide poisoning ?

A

Caused by the incomplete combustion of carbon
Binds to job as 200x more affinity than oxygen
Left shift
Also binds to cytochrome oxidase

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12
Q

How does amyl nitrate work As an antidote for cyanide?

A

Hb is converted to methhaemoglobin (fe2+ to fe3+)

Cyanide has a greater affinity to methb and therefore binds to that preferentially over hb

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13
Q

What is the management of cyanide poisoning?

A 
Ppe- as it absorbs through the skin
Gastric lavage
Amyl nitrate 
Hydroxycobalamine (routinely )
Sodium thiosulphate (slow)
Dicobalt edatate (toxic)
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14
Q

What are the Features of cyanide poisoning ?

A 
Confusion 
Seizures
Lactic acidosis
Raised svco2
Tachycardia
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15
Q

What is the actions of cyanide in a poisoning?

A

Reversible binds to and inhibits cytochrome oxidase in mitochondria and therefore disrupts electron transport and causes anaerobic respiration and leads to cytotoxic hypoxia

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16
Q

How does formepizole work?

A

Alcohol dehydrogenase inhibitor

As AD has a greater affinity for ethanol it prevents metabolism of alcohol to toxic metabolites

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17
Q

What are the toxic effects of methanol and ethanol dehydrogenase?

A

Methanol:
Metabolic acidosis (due to decreased mitochondrial function)
Optic nerve toxicity

Ethylene glycol
Cerebral oedema
Metabolic acidosis
Renal Failure

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18
Q

What is the treatment of neuroleptic malignant syndrome?

A

Benzodiazepines
Dantrolene
Bromocriptine

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19
Q

What are the features of neuroleptic malignant syndrome?

A

Rigidity
Fever
Autonomic instability

Increased CK and WCC

Over a long time

-dopaminergic blockade

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20
Q

What causes neuroleptic malignant syndrome?

A

Antipsychotics

Dopamine antagonists

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21
Q

What is the Management of tricyclics antidepressant overdose?

A 
Activated charcoal 
Forced alkaline diuretics to a blood Ph of >7.45
Hyperventilation 
Mgso4
Lidocaine for the tachyarrythmias
Benzodiazepines
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22
Q

What are the features of a tricyclics antidepressant overdose?

A 
Sludge 
Tachyarrythmias (phase 0 slows therefore prolonged QRS)
Low consciousness
Depressed resp drive
Prolonged gastric emptying time
Warm and dry skin
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23
Q

What is the treatment of salicylate toxicity?

A

Activated charcoal
Forced alkaline diuresis
Urine 6-7 blood 7.4-7.5

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24
Q

What is the presentation of salicylate poisoning?

A 
Fever
Tinnitus
Low BMs
Coagulopathy
Pulmonary oedema
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25
What is the kings criteria for non paracetamol induced liver failure ?
INR >6.5 OR ``` 3 of Age less than 11 or over 40 Non A or B hepatitis or drug reaction Jaundice -> encephalopathy over 7 days (not hyperacute) Bili> 300 ```
26
What are the kings criteria for paracetamol OD?
Ph >7.3 Or INR >6.5 PT > 100 s Creat > 300 Encephalopathy grade 3-4
27
How does NAC work and what are the side effects ?
Binds to NAPQi and stimulates glutathione production Rash angioedema and bronchospasm
28
How is paracetamol metabolised ?
Normally metabolised in the liver with a small amount metabolised via p450 system to a toxic metabolite NAPQI NAPQI is bound to glutathione and excreted In an OF glutathione stores are overwhelmed leading to hepatotoxicity
29
What causes sympathimimetic toxidromes ?
Cocaine Amphetamines Salbutamol
30
What are the features of symphatomimetic toxidromes?
``` Paranoia Tachycardia Hypertension Increased reflexes Goose pimples Sweaty ```
31
What is the Treatment of seretonin syndrome?
Benzodiazepines | Cyproheptadine (serotonin antagonist)
32
What are the causes of seretonin syndrome?
``` Antidepressant Amphetamines Ecstasy Tramadol and pervasive Linezolid and tetracyclines ```
33
What are the clinical features of seretonin syndrome?
Altered mental state Neuromuscular hyperactivity Autonomic dysfunction. ``` Tremor Nystagmus Pyrexia Seizures Rhabodmyalysis ```
34
Talk me through Hunters criteria
One of the following ``` Spontaneous clonus Clonus and agitation Nystagmus and agitation Pyrexia and clonus Tremor and hyper reflex is ```
35
What are the causes of anticholinergic toxidromes ?
``` Antihistamine (chlorphenmine) Antidepressants (TCA) Anti convulsants (carbamazepine) Antipsychotics (H Q O) Atropine ```
36
What are the features of anticholinergic toxidromes?
``` Dry skin Urinary retention Tachyarrythmias Fevers Hypotension ```
37
How do you manage a cholinergic crisis ?
Atropine Pralidoxime- Anticholinesterase reactivator Benzodiazepines
38
What causes a cholinergic crisis?
Nerve agents MG - cholinergic inhibitor OD Organophosphate so
39
What are the features of a cholinergic toxidromes?
``` S - salivation L - lacrimation U - urination D - diarrhoea G - GI cramps E - emesis ```
40
What is the framework for toxicology emergencies?
Resus the life threatening physiology Identify agent and dosing Limit absorption Antidotes Supportive care
41
What is the anion equation ?
(Na + k ) - (cl + hc03)
42
What is a normal anion gap ?
4- 12
43
What raises the anion gap ?
``` C cyanide A alcohol ketoacidosis and starve T toluene M met Forman methanol U uraemia D dka P paracetamol paraldehyde I isoniazid iron L lactic acidosis E ethylene glycol S salicylates ```
44
Osmolar gap calculation.
Measured - calculated osmolality 2 na + k + urea + glucose
45
I what is a normal osmolar gap ?
<10 mOsm l-1
46
Causes of a raised osmolar gap ?
``` B benzodiazepines S sorbitol M mannitol methanol P phenytoin I IVIG T TURP syndrome E ethylene glycol ```
47
What are the causes of normal anion gap ?
A addisons acetazomide B bicarbonate loss (RTA and GI) C chloride excess
48
What are the causes of a low anion gap ?
``` M multiple myeloma E electrolytes (raised na / ca /mg) D dilutional A albumin loss / amphoteracine L lithium ```
49
What is ethylene glycol found In?
``` Antifreeze Detergents Break fluid Solvent Paint ```
50
What drugs do activated charcoal NOT eliminate?
Metals Strong acids and alkali Alcohol Cyanide
51
What is foxes alkaline diuresis used to eliminate?
Aspirin Methotrexate Phenobarbital
52
How does forced alkaline diuresis work?
Eliminates low Pka drugs Infusion of IV bicarbonate and furosemide Aim urine ph 7.5 Acid drugs are converted to the ionic form in the alkali condition and therefore not absorbed in the glomerulus
53
What are the characteristics of the drugs removed by RRT?
Small < 500 DA Water soluble Low protein binding Small volume of distribution
54
What Drugs are removed by HD?
B beta blockers D dabigatrans S sodium valproate M metformin methotrexate A anticonvulsants L lithium
55
Which patients do not require treatment with NAC following a staggered paracetamol OD
If Paracetamol level < 10 and Inr <1.3 and Alt normal and No symptoms of liver damage
56
How does nac work
Replenishes glutathione stores which prevents the toxic paracetamol metabolite NAP QI from building up and causing direct hepatocellular damage
57
What is the kings college criteria for transplant in paracetamol toxicity
Ph < 7.3 following fluid resus at > 24hrs Or Within 24 hours , All three of : Inr > 6.5 or PT > 100 Creatinine > 300 Grade 3/4 encephalopathy Or Lactate 3.5 after 4 hour with fluid resus Or Ph <7.3 and lactate >3 after 12 hours
58
King college criteria for referral for transplant in non paracetamol liver failure
Inr >6.5/ PT > 100 Or - under 10 over 40 - billi > 300 - more than 10 days between onset of jaundice and encephalopathy - PT > 50
59
Describe the MeLd score and it’s use
Logarithmic calculation of bilirubin creatinine and INR and if on dialysis Predicts 90 day survival Score of 40 - 70% mortality
60
What do you use to treat local anaesthetic toxicity
Intravenous lipid emulsion 1.5mls/ kg bolus 1.5mg/kg x3 at 5 min intervals in an arrest 15mls/ kg /hr and double the rate of infusion if patient remains in arrest Hyperventilate the patient
61
What is the mechanisms of action for tCA overdose
Anticholinergic Inhibition of noradrenaline and seronergic reuptake Blockade of sodium fast channels
62
What is the antidote for lidocaine
Intra lipid
63
What is the antidote to cyanide
Dicobalt edatate Sodium nitrite Sodium thiosulphate Hydroxycobalamin
64
What is the antidote for sulphinylureas
Glucose | Octreotide
65
What is the antidote for b blockers
Glucagon | Atropine
66
What is the calculated osmolality equation
2na+ glucose + urea Normal is <10
67
What is PRIS blood finding
Unexplained metabolic acidosis Raised CK , K and AKI Myppglobinuria Hyper triglycerides
68
Pathophysiology of PRIS
Impaired mitochondrial fatty acid metabolism Anaerobic respiration and lactate production. And prop is a direct myocardial depressant
69
Ecg changes in PRIS
Bradycardia Brugada like st changes V1-3 Heart block rBBB

Icm (16 decks)

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