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Icm > Toxicology > Flashcards

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
Q

What is the kings criteria for non paracetamol induced liver failure ?

A

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
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26
Q

What are the kings criteria for paracetamol OD?

A

Ph >7.3

Or

INR >6.5
PT > 100 s
Creat > 300
Encephalopathy grade 3-4

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27
Q

How does NAC work and what are the side effects ?

A

Binds to NAPQi and stimulates glutathione production

Rash angioedema and bronchospasm

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28
Q

How is paracetamol metabolised ?

A

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
Q

What causes sympathimimetic toxidromes ?

A

Cocaine
Amphetamines
Salbutamol

30
Q

What are the features of symphatomimetic toxidromes?

A 
Paranoia
Tachycardia
Hypertension
Increased reflexes
Goose pimples
Sweaty
31
Q

What is the Treatment of seretonin syndrome?

A

Benzodiazepines

Cyproheptadine (serotonin antagonist)

32
Q

What are the causes of seretonin syndrome?

A 
Antidepressant 
Amphetamines
Ecstasy
Tramadol and pervasive
Linezolid and tetracyclines
33
Q

What are the clinical features of seretonin syndrome?

A

Altered mental state
Neuromuscular hyperactivity
Autonomic dysfunction.

Tremor
Nystagmus 
Pyrexia
Seizures
Rhabodmyalysis
34
Q

Talk me through Hunters criteria

A

One of the following

Spontaneous clonus
Clonus and agitation 
Nystagmus and agitation 
Pyrexia and clonus
Tremor and hyper reflex is
35
Q

What are the causes of anticholinergic toxidromes ?

A 
Antihistamine (chlorphenmine)
Antidepressants (TCA)
Anti convulsants (carbamazepine)
Antipsychotics (H Q O)
Atropine
36
Q

What are the features of anticholinergic toxidromes?

A 
Dry skin 
Urinary retention
Tachyarrythmias 
Fevers
Hypotension
37
Q

How do you manage a cholinergic crisis ?

A

Atropine
Pralidoxime- Anticholinesterase reactivator
Benzodiazepines

38
Q

What causes a cholinergic crisis?

A

Nerve agents
MG - cholinergic inhibitor OD
Organophosphate so

39
Q

What are the features of a cholinergic toxidromes?

A 
S - salivation
L - lacrimation
U - urination
D - diarrhoea
G - GI cramps
E - emesis
40
Q

What is the framework for toxicology emergencies?

A

Resus the life threatening physiology

Identify agent and dosing

Limit absorption

Antidotes

Supportive care

41
Q

What is the anion equation ?

A

(Na + k ) - (cl + hc03)

42
Q

What is a normal anion gap ?

A

4- 12

43
Q

What raises the anion gap ?

A 
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
Q

Osmolar gap calculation.

A

Measured - calculated osmolality

2 na + k + urea + glucose

45
Q

I what is a normal osmolar gap ?

A

<10 mOsm l-1

46
Q

Causes of a raised osmolar gap ?

A 
B benzodiazepines 
S sorbitol
M mannitol methanol
P phenytoin
I IVIG
T TURP syndrome
E ethylene glycol
47
Q

What are the causes of normal anion gap ?

A

A addisons acetazomide
B bicarbonate loss (RTA and GI)
C chloride excess

48
Q

What are the causes of a low anion gap ?

A 
M multiple myeloma
E electrolytes (raised na / ca /mg)
D dilutional
A albumin loss / amphoteracine
L lithium
49
Q

What is ethylene glycol found In?

A 
Antifreeze
Detergents 
Break fluid
Solvent 
Paint
50
Q

What drugs do activated charcoal NOT eliminate?

A

Metals
Strong acids and alkali
Alcohol
Cyanide

51
Q

What is foxes alkaline diuresis used to eliminate?

A

Aspirin
Methotrexate
Phenobarbital

52
Q

How does forced alkaline diuresis work?

A

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
Q

What are the characteristics of the drugs removed by RRT?

A

Small < 500 DA
Water soluble
Low protein binding
Small volume of distribution

54
Q

What Drugs are removed by HD?

A

B beta blockers
D dabigatrans
S sodium valproate
M metformin methotrexate

A anticonvulsants
L lithium

55
Q

Which patients do not require treatment with NAC following a staggered paracetamol OD

A

If

Paracetamol level < 10 and
Inr <1.3 and
Alt normal and
No symptoms of liver damage

56
Q

How does nac work

A

Replenishes glutathione stores which prevents the toxic paracetamol metabolite NAP QI from building up and causing direct hepatocellular damage

57
Q

What is the kings college criteria for transplant in paracetamol toxicity

A

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
Q

King college criteria for referral for transplant in non paracetamol liver failure

A

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
Q

Describe the MeLd score and it’s use

A

Logarithmic calculation of bilirubin creatinine and INR and if on dialysis

Predicts 90 day survival

Score of 40 - 70% mortality

60
Q

What do you use to treat local anaesthetic toxicity

A

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
Q

What is the mechanisms of action for tCA overdose

A

Anticholinergic
Inhibition of noradrenaline and seronergic reuptake
Blockade of sodium fast channels

62
Q

What is the antidote for lidocaine

A

Intra lipid

63
Q

What is the antidote to cyanide

A

Dicobalt edatate
Sodium nitrite
Sodium thiosulphate
Hydroxycobalamin

64
Q

What is the antidote for sulphinylureas

A

Glucose

Octreotide

65
Q

What is the antidote for b blockers

A

Glucagon

Atropine

66
Q

What is the calculated osmolality equation

A

2na+ glucose + urea

Normal is <10

67
Q

What is PRIS blood finding

A

Unexplained metabolic acidosis
Raised CK , K and AKI
Myppglobinuria
Hyper triglycerides

68
Q

Pathophysiology of PRIS

A

Impaired mitochondrial fatty acid metabolism
Anaerobic respiration and lactate production.
And prop is a direct myocardial depressant

69
Q

Ecg changes in PRIS

A

Bradycardia
Brugada like st changes V1-3
Heart block
rBBB

Icm (16 decks)

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