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Toxicology Flashcards

1
Q

Initial naloxone dose for young/opioid naive children

A

0.1mg/kg

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2
Q

Initial naloxone dose for adolescent/at risk of withdrawal

A

0.04mg

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3
Q

Maximal therapeutic dose acetaminophen

A

Children - 90mg/kg/d
Adults - 4g/d

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4
Q

Toxic dose acetaminophen

A

150mg/kg in < 24hrs
10g in < 24hrs

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5
Q

What is the toxic metyabolite of acetaminophen that causes hepatotoxicity?

A

NAPQI

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6
Q

What produc detoxifies NAPQI?

A

glutathione

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7
Q

How does NAC work?

A

= glutathione precursor

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8
Q

What are the stages of acetaminophen toxicity?

A

Stage 1 - 0.5-24hrs post-ingestion. Asymptomatic or GI symptoms, possible ALOC and elevated anion gap acidosis

Stage 2- 24-72 hours. Hepatotoxic signs with RUQ pain, possible AKI but improvement of GI symptoms

Stage 3 - 72-96hrs. Fulminant hepatitis with return of GI symptoms, possible encephalopathy, metyabolic acidosis, AKI, coagulopathy, possible multisystem dysfunction and death

Stage 4 - 4d-2wks. Recuperation

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9
Q

If patient comes in with ingestion > 8hrs ago or unknown time, how do you manage?

A

Start NAC immediately and refer to nomogram once results available

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10
Q

What are the criteria for being able to use the nomogram?

A

Single ingestion or over < 8hrs
bloodwork done 4-24hrs post-ingestion

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11
Q

What are indications for use of NAC?

A

APAP > 66
Abnormal transaminases (do at least 2 checks)

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12
Q

When can NAC treatment be stopped?

A

If APAP dose not toxic based on nomogram
At end of treatment if acetaminophen negative and normal transaminases

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13
Q

What are secondary effects of NAC?

A

elevated INR
flushing
urticaria
angioedema
dyspnea/hypotension

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14
Q

What is the therapeutic dose of activated charcoal?

A

1g/kg, max 50g

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15
Q

When would you consider more than one dose of activated charcoal?

A

large quantity of ingested pills, especially if salicylate
ingestion of substance that slows gastric emptyin
extended release pill
enterosoluble pill
blood concentration of substance continues to increase

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16
Q

What are contraindications to use of charcoal?

A

lithium, heavy metals, alcohols
inadequate protection of airways
intestinal occlusion
ingestion of corrosive substance

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17
Q

What substances warrant repeated charcoal doses?

A

theophylline, caffeine, phenobarbital, carbamazepine, dapsone, quinine, amatotoxine (mushrooms)

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18
Q

What are the doses for repeated activated charcoal?

A

1g/kg q4h or 0.5g/kg q2h

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19
Q

What bloodwork should be done if not able to get history in comatose/ALC patients?

A

CBC, uric acid, Cr, lytes, transaminases, gas, serum osmolality, EtOH, ECG, APAP/ASA dosing

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20
Q

What is the calculation for anion gap?

A

Na - (Cl + HCO3)

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21
Q

What are the substances that cause elevated anion gap metabolic acidosis

A

Methanol
Uremia
Diabetic ketoacidosis (DKA)

Paraldehyde, phenformin;
Iron, isoniazid
Lactic (ie, carbon monoxide [CO], cyanide)
Ethylene glycol
Salicylates

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22
Q

How do you calculate osmolality?

A

2Na + Glucose + BUN (2 salts and a sugar bun)

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23
Q

What is a normal osmolar gap value?

A

< 10

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24
Q

What toxins cause elevated osmolar gap?

A

Ketones
Alcohols**

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25
What anti-arhythmic medication should be avoided in cases of toxic OD?
Amiodarone
26
What is the electrolyte-channel associated with enlarged QRS?
Sodium channel blocker
27
What is the electrolyte-channel assoiciated with prolonged QTc?
Potassium channel blocker
28
In what toxidromes should beta-blockers be avoided?
sympathomimetic, anticholinergic, serotoninergic
29
What drug should be dosed + consider administration of its antidote in tachycardia?
digoxin
30
What substances are sodium channel blockers?
quinine procainamide TCA lidocaine phenytoine local anesthetics cocaine chloroquine
31
How do you treat widened QRS caused by sodium channel blockers?
Sodium carbonate 1-2mmol/kg IV in 1-2 mins Repeat until QRS < 100 or until BP stabilized and ECG normal OR Try NaCl 3%
32
What substances cause long QTc/torsades de pointe by Potassium cannel blockers?
sotalol etc macrolides psychotropic meds methadone domperidone
33
How do you treat long QTc/torsades de pointe caused by Potassium cannel blockers?
Magnesium sulfate 1-2g IV
34
What are the symptoms of anticholinergic toxidromes?
DRY Delirium/agitation/hallucinations Mydriasis Hypertension Tachycardia Tachympia Possible urinary retention Hyperthermia Redness Hyperreflexia/trembling
35
What are the symptoms of Cholinergic toxidromes? (Muscarinic)
WET - delirium/depression - Myosis - Salivation + tearing - Hypotension - Bradycardia Bronchospasm Increased GI motility Incontinence Vomiting/cramps/diarrhea Diaphoresis
36
Cholinergic (nicotinic) toxidrome?
WET mydriasis hypertension tachycardia fasciculations weakness hyper then hyporeflexia + paresis
37
Sympathomimetic toxidrome
delirium/agitation mydriasis hypertension tachycardia tachypnea no GI/Urinary symptoms hyperthermia diaphoresis hyperreflexia trembling
38
Opioid toxidrome
confusion/somnolence myosis hypotension bradycardia bradypnea hypothermia hyporeflexia
39
Serotoninergic toxidrome
delirium/agitation mydriasis hypertension tachycardia tachypnea increased GI peristalsis hyperthermia diaphoresis clonus hypertonia hyperreflexia tremors bruxism
40
Examples of methanol-containing toxins
fondue liquid anti-freeze
41
Lab findings in methanol + ethylene glycol poisoning
starts with elevated osmolar gap then elevated anion gap metabolic acidosis (methanol = elevated formic acid, ethylene glycol = oxalic acid)
42
Antidotes to methanol + ethylene glycol poisoning
Fomepizole Ethanol
43
How much methanol can cause significant intoxication
0.25ml/kg 4-10 mL can cause permanent blindness
44
What are the clinical symptoms of methanol poisoning?
GI symptoms - nausea, vomiting, anorexia, abdo pain, pancreatitis neurologic symptoms - depression, headache, compa, convulsions, cerebral edema, possible basal ganglia effects Visual disturbance - "snowstorm", central scotoma, papilledema Tachycardia, hypotension Tachypnea initially followed by respiratory depression
45
What are examples of ethylene glycol containing toxins?
antifreeze
46
Toxic quantity of ethylene glycol
0.2ml/kg 1-1.5ml/kg = lethal
47
Clinical symptoms of ethylene glycol poisoning
GI - nausea, vomiting, ado pain Neuro - depression, seizure, cerebral edema, coma, polyradiculopathy, IC hemorrhage Renal - AKI, oxaluria, hypocalcemia, tetany Leucocytosis, hyperglycemia tachycardia QTc prolongation CHF tachypnea then resp failure pulmonary edema
48
What labs need to be done for toxic alcohol poisoning?
Concentration 1.5-2hrs post ingestion then repeat q 4-8hrs CBC, Electrolytes inc Ca, BUN. Cr, glycemia, hepatic enzymes, lipase, troponin, CK EtOH, serum osmolality, gas, lactate ethylene glycol - UA looking for calcium oxalate crystals
49
Products containing isopropanol
rubbing alcohol, solvants, some antifreeze
50
Lab changes in isopropanol poisoning
elevated Ketones Elevated osmolar gap NO metabolic acidosis
51
Clinical symptoms of isopropanol poisoning
Fruity breath (acetone) CNS depression nausea, vomiting, abdo pain hemorrhagic gastritis acute pancreatitis (rare) Severe - coma, hypotension, hypothermia, arhythmias, AKI
52
Labs to do for suspected isopropanol poisoning
CBC, Lytes, BUN, Cr, glucose Hepatic enzymes, lipase concentration of isopropanol and acetone (metabolizes to acetone) other alcohols ketones blood gas serum osmolality UA - ketones
53
Treatment for isopropanol poisoning
symptomatic treatment
54
Indications for use of Fomepizole
Methanol > 6mmol/L Ethylene glycol > 3mmol/L Metabolic acidosis with osmolar gap > 10 without clear reason false hyperlactatemia
55
Dose of fomepizole
15mg/kg IV over 30 mins 12 hrs later give 10mg/kg iV over 30 mins - repeat q12h x 4 doses
56
When can fomepizole be stopped?
resolution of metabolic acidosis methanol < 6 mmol/L or ethylene glycol < 3 mmol/L
57
What adjunct treatments can be given in methanol poisoning?
leucovorin (folic acid) 1mg/kg/dose IV
58
What adjunct treatment can be given for ethylene glycol poisoning?
Pyridoxine 50mg q6h + thiamine 100mg IV q8h
59
What are indications for hemodialysis in methanol poisoning?
visual symptoms coma seizures methanol > 15-22 pH < 7.15
60
What are indications for hemodialysis in ethylene glycol poisoning?
AKI EG > 8 pH < 7.15
61
What is a possible systemic toxic effect of OD of local anesthetics?
Methemoglobinemia - topical and oral use of benzocaine CNS - tinnitus, dizziness, lingual/peribuvval numbness, visual changes, hearing changes, confusion, tremor, seizures, coma CV (higher concentrations) - shock, vascular collapse, sodium channel block
62
What local anesthetic is most cardiotoxic?
Bupivacaine
63
What is the antidote for local anesthetic OD?
Intralipids
64
What medications have anticholinergic effects?
atropine scopolamine glycopyrrolate TCAs antihistamines antipsychotics antispasmodics antiparkinsoniens (benztropine) muscle relaxants anticonvulsants - carbamazepine belladonna plant
65
What labs need to be done for anticholinergic ingestion?
Cardiac monitoring CK - if agitation, convulsion, compa Lytes, BUN, Cr UA - myoglobinuria if suspected rhabdomyolysis
66
What is the antidote for anticholinergics?
Physostigmine - only if pure anticholinergic ingestion, severe and refractory to other treatments Dose 0.02mg/kg (max 0.5mg) IV max rate 1mg/min Can repeat q 10-30 mins - max 2mg cumulative dose
67
What is a contraindication to physostigmine use?
evidence of sodium channel block
68
Symptoms of TCA overdose
Antihistamine - Sedation Anti-muscarinic - agitation, hallucinations, delirium, tachycardia, hyperthermia, mydriasis, dryness, ileus, urinary retention Alpha adrenergic - hypotension, reflex tachycardia Diaphoresis, tachycardia Serotonin syndrome Sodium channel blocker - large QRS, brugada, seizures Potassium channel blocker - QTc prolongation GABA antagonists
69
What is the best prognostic parameter to prognosticate risk of arrhythmia and seizure in TCA intox?
ECG - R wave in aVR > 3mm
70
Treatment of TCA overdose
Consider if in cardiogenic shock. If yes, will respond well to NaHCO3 administration If large QRS give 1-2mmol/kg IV of NaHCO3 boluses - goal = pH 7.45-7.55
71
What medications are "one pill killers"?
- benzocaine – methemoglobinemia and seizures - β-blockers – bradycardia, hypotension, seizures - calcium channel blockers - bradycardia, hypotension - camphor – seizures, CNS depressant - chloroquine – seizures, arrhythmia - clonidine – bradycardia, CNS depression - diphenoxylate/lomotil – CNS and respiratory depression - hypoglycemics (sulfonylureas) – hypoglycemia - Lindane – seizures, CNS depression - methyl salicylate (oil of wintergreen) – seizures, CVS collapse - phenothiazines – seizures, arrhythmia - quinidine – seizures, arrhythmia - theophylline – seizures, arrhythmia - TCAs – Seizures, CVS collapse, hypotension
72
What medication does oleander ingestion mimic?
digoxin
73
What are the signs of oleander toxicity?
vomiting, diarrhea, abdominal pain, weakness, confusion, hyperkalemia, and bradyarrhythmias, especially high grade atrioventricular block
74
What are the signs of hemlock toxicity?
spontaneous vomiting within 1 hour. Salivation, headache, fever, mental confusion, and muscular weakness may follow, and the child may deteriorate to convulsions, coma, and death from respiratory failure.
75
what is the toxidrome of jimsonweed toxicity?
anticholinergic
76
Antidotes for the following med classes: Acetaminophen Antichoninergic Anticholinesterase Organophosphates Benzos Beta blockers Calcium channel blockers Digitalis Fluoride Iron Isoniazid Methanol/ethylene glycol Methemoglobinemia Opoioids Sulfonylureas TCAs Warfarin
Acetaminophen - NAC Antichoninergic - Physostigmine Anticholinesterase - atropine Organophosphates - pralidoxime Benzos - flumazenil Beta blockers - glucagon Calcium channel blockers - CaCl or CaGluconate + insulin/glucose Digitalis - digibind Fluoride - calcium gluconate Iron - deferoxamine Isoniazid - pyridoxine Methanol/ethylene glycol - fomepizoe, ethanol, folate, thiamine Methemoglobinemia Opioids - naloxone Sulfonylureas - octreotide TCAs - sodium bicarb Warfarin - vit K
77
78
Possible side effect of repeated doses of succinylcholine
*bradycardia Hypotension Arrhythmia MI Prolonged paralysis Hyperkalemia and ventricular arrhythmias in patients in catabolism or with muscular trauma
79
Stages of ethylene glycol poisoning
Stage 1 CNS – profound metabolic acidosis, tachycardia, mild HTN, leukocytosis, nausea/vomiting, convulsions + coma, hypocalcemia Stage 2 Coma + cardiopulmonary failure – result of acidosis Stage 3 Renal failure – ATN requiring dialysis
80
What are the final toxic products in the metabolism of ethylene glycol?
Glycoaldehyde, glycolic acid, oxalate
81
What chemicals should not be immediately irrigated?
Dry lime Elemental metals Phenol
82
Side effects of physostigmine
seizures asystole cholinergic crisis
83
3 antidotes for methanol
ethanol folate fomepizole
84
Meds that are dangerous to toddlers in 1-2 doses
benzocaine betablockers calcium antagonists/calcium channel blockers camphor (eg. vicks vapo rub) chloroquine clonidine lomotil glyburide lindane methyl salicylate opioids chlorpromazine quinidine quinine theophylline TCAs
85
5 stages of iron toxicity
Stage 1 (0-6h) - GI symptoms, if severe can have GI bleeding Stage 2 (6-24h) - latent, no GI sx, lethargy, tachycardia, metabolic acidosis Stage 3 (24-72h) - shock, GI hemorrhage, coagulopathy, worsening metabolic acidosis, convulsion, coma Stage 4 (2-3d) - hepatic failure Stage 5 (long term) - intestinal stenosis, scarring, pyloric stenosis
86
Indications for deferoxamine
ingestion > 40mg/kg of elemental iron with GI symptoms or lethargy Iron > 90 micromol/L OR iron > 63micromol/L with CV symptoms or metabolic acidosis
87
Starting dose of deferoxamine
15mg/kg/hr
88
When can deferoxamine treatment be stopped?
decontamination is done no more symptoms no more lactic acidosis
89
side effects of deferoxamine
urticaria or erythema hypotension ARDS RED/PINK URINE
90
TCA clinical findings in OD
sedation or agitation hallucinations/delirium tachycardia hyperthermia mydriasis dry mouth/skin ileus urinary retension hypotension QRS prolongation, brugada seizures QTc prolongation
90
Most accurate way to predict arrhythmogenic and convulsive risk in TCA overdose
ECG shows R in aVR > 3mm
91
Labs in TCA OD
lytes, BUN, creatinine, hepatic enzymes, CK lactate, gas Urinalysis for myoglobinuria
92
Signs of mild to moderate bupropion toxicity
tachycardia and hypertension agitation dizziness tremors paresthesias lethargy confusion seizures
93
Signs of severe bupropion toxicity
hyperthermia hypotension QRS prolongation QTc prolongation ventricula arrhythmias status epilepticus coma
94
How long does patient with toxic ingestion of bupropion need to have ECG monitoring?
18-20 hours post ingestion if asymptomatic or minimum 12h post end of symptoms
95
Symptoms of IMAO toxicity
hyperthermia nausea/vomiting/diarrhea mydriasis ocular clonus redness diaphoresis headache delirium neuromuscular symptoms hypertension initially followed by hypotension possible MI
96
which SSRI is at risk of causing late-presenting torsades de pointes/
citalopram
97
How long does ECG monitoring need to continue for citalopram or escitalopram ingestion?
24hrs minimum
98
How long does clinical monitoring need to continue for SSRI ingestion?
18-20 hours post ingestion if asymptomatic or minimum 12h post end of symptoms
99
Mirtazipine toxicity clinical signs
tachycardia dizziness altered LOC hypothermia dry mouth constipation elevated transaminases QRS prolongation
100
Trazodone toxicity clinical signs
lethargy dizziness myoclonus ataxia seizures nausea/vomiting respiratory depression hypotension bradycardia mydriasis priapism hyponatremia hypokalemia
101
Venlafaxine + Duloxetine toxicity
seizures altered LOC nausea/vomiting tachycardia hypotension diaphoresis hyperthermia QRS and QTc prolongation hyponatremia rhabdomyolysis transaminitis
102
Clinical presentation of neuroleptic malignant syndrome
hyperthermia rigidity (cogwheel) altered LOC autonomic instability - tachycardia, diaphoresis, hypersalivation, incontinence, irregular respiration, arrhythmia, hyper or hypotension leucocytosis rhabdomyolysis myoglobinuria AKI
102
Risk factors for neuroleptic malignant syndrome
recent initiation of antipsychotic medication or dose increase young age male dehydration co-treatment with lithium combination of multiple agent rapid dose increases
103
Betablocker toxicity
decreased contractility bradycardia confusion altered LOC/coma nausea/vomiting bronchospasm hyperkalemia pulmonary edema HypOglycemia
104
Which betablocker can cause torsades de pointe?
sotalol
105
Calcium channel blocker toxicity
vasodilation of arteries decreased contractility bradycardia confusion altered LOC/coma nausea/vomiting pulmonary edema HypERglycemia
106
Indications for pralidoxime use in cholinergic toxicity
presence of nicotinic signs or CNS signs with only an organophosphate or mixed with carbamate insecticide
107
Acute digoxin intoxication
nausea + vomiting* hyperkalemia (marker of severity in acute ingestion) bradycardia, AV block, VT/VF lethargy comfusion weaknessA
108
Chronic digoxin intoxication
predominant neuro symtoms - delirium, comfusion, somnolence, hallucinations, photophobia, blurred vision, scotoma, chromatopsy (seeing yellow haloes) GI symtpoms Electrolyte abnormalities secondary to chronic renal insufficiency bradycardia slow AF AV block bigeminy/trigeminy VT
109
Pathognomonic arrhythmia for chronic digoxin intoxication
Bidirectional ventricular tachycardia
110
When should digoxin levels be drawn
6hrs post ingestion
111
What is the antidote for digoxin intoxication?
Digoxin-specific antibody antigen-binding fragments (DSFab)
112
Indications for use of Digoxin-specific antibody antigen-binding fragments (DSFab)
symptomatic and progressive bradyarrhythmia 2nd or 3rd degree AV block resistant to atropine tachycardia or Vfib Digoxin level > 12.8 6hrs+ post ingestion Potassium > or equal to 5
113
What dose of iron is toxic?
> 30mg/kg of elemental iron or iron > 32micromol/L 4h post-ingestion
114
Examples of oral hypoglycemic agents that increase insulin release
sulfonylureas - eg. glipizide, glyburide, chlorpropamide Gliptines - sitagliptine, saxagliptin GLP-1 analogs - exenatide meglitinides - nateglinide, repaglinide
115
Up to when can symptoms of sulfonylurea toxicity appear
up to 24hrs post
116
Effects of oral hypoglycemics with increased insulin release - toxicity
hypoglycemia** Neuro sx - seizure, delirium, coma tremor sweating tachycardia hypokalemia hypomagnesemia hypophosphatemia mild hypothermia
117
Effects of metformin OD
unlikely to cause hypoglycemia mild-moderate: nausea, vomiting, abdo pain, myalgia Severe: severe lactic acidosis, cNS depression, hypothermia, tahypnea, hypotension, AKI
118
Toxic dose of metformin for children
> 1.7g
119
Which oral hypoglycemic can cause QTc prolongation?
sitagliptin
120
What is the antidote for oral hypoglycemics?
Octreotide
121
When is octreotide administration indicated
recidivant hypoglycemia induced by a sulfonylurea or no IV access
122
When can octreotide treatment cease?
absence of hypoglycemia x 24h after last dose of octreotide including an 8hr period of fasting
123
Dose of dextrose to give to correct hypoglycemia caused by oral hypoglycemics
0.5g/kg followed by a perfusion of 0.5g/kg/h
124
Dose of glucagon for hypoglycemia
20-30mcg/kg IM
125
Risk associated with intox by hypoglycemic agents in a patient already on beta blockers or co-ingested with beta-blocker
may not present adrenergic manifestations of hypoglycemia
126
Causes of methemoglobinemia
Local anesthetics (Eg. benzocaine, lidocaine) Nitrates and Nitrites Antimicrobials (eg. chloroquine, dapsone) bromates chlorates metoclopramide nitrous oxide nitroglycerin napthelene
127
What age group is most at risk for methemoglobinemia in pediatrics?
< 36 months
128
Risk factors for developing methemoglobinemia
anemia malnutrition renal insufficiency sepsis acidosis G6PD deficiency
129
In which patients should methemoglobinemia be considered?
cyanosis that does not fit with clinical picture and does not respond to O2 administration
130
Antidote for methemoglobinemia
methylene blue 1% 1-2mg/kg in 5 min IV repeated 30-60 mins later if needed
131
When can methylene blue treatment be stopped?
max dose 7mg/kg no more symptoms
132
Secondary effects of methylene blue
blue/green coloured urine, stool and skin nausea, vomiting, headache, abdo pain, vertigo, hypotension, dyspnea superficial thrombophlebitis
133
Lithium toxicity (acute)
GI predominant - nausea, vomiting, diarrhea CNS (late signs) ECG - flattened or inverted T waves, QTc prolongation, bradycardia
134
Lithium toxicity (chronic)
Nervous predominant - tremor, hyperreflexia, clonus, fasciculations, nystagmus, ataxia, dysarthria, seizures somnolence, confusion, coma
135
what is SILENT?
syndrome of irreversible lithium-effectuated neurotoxicity
136
Treatment of lithium toxicity
hydration at 1.5-2x maintenance regular monitoring of electrolytes and renal function hemodialysis - consider
137
Salicylate toxic dose
150-200mg/kg
138
Examples of salicylate-containing products
ASA Methyl salicylate (tea tree essential oil + wintergreen) pepto-bismol
139
3 stages of salicylate toxicity
1 - hyperventilation diaphoresis vomiting tinnitus hypoacusis respiratory alkalosis hypokalemia alkaline urine with high K+ 2 - hyperglycemia volume contraction deterioration elevated anion gap hypokalemia acid urine 3 - hyperthermia pulmonary edema possible hepatotoxicity hypoglycemia confusion/coma seizures CV collapse acid urine acidosis (blood) Also: SIADH (hyponatremia) or dehydration (hypernatremia), ketonuria more rarely: rhabdomyolysis, GI hemorrhage
140
How often to monitor salicylate levels?
q2hrs
141
how often to measure urine pH in salicylate toxicity?
q1h
142
Treatment of salicylate toxicity
charcoal decontamination administer dextrose Urine alkalanization - pH 7.5-8, plasma alkalanization (ifpH < 7.4) using sodium bicarbonate (2-3ml/kg/hr max 150-200ml/hr) prevent hypokalemia consider hemodialysis
143
Why do we do urine/plasma alkalanization in salicylate toxicity?
higher pH = salicylates more ionized = decreased absorption in the renal tubules = increased excretion
144
Serotonin syndrome
myoclonia, tremor and hyperreflexia (predominant sxs) clonus hyperthermia ocular clonus rigidity
145
Medications that are NOT SSRI/SNRI that can cause serotonin syndrome
methylene blue linezolid bupropion cocaine dextromethorphan fentanyl tramadol trazodone LSD amphetamines MDM buspirone lithium mirtazapine
146
Major differentiating factor between NMS vs serotonin syndrome
Serotonin syndrome = faster onset, more tremor, myoclonia and hyperreflexia NMS = slower/delayed onset, rigidity and bradykinesia more prominent
147
antidote to serotonin syndrome
cyproheptadine 1-2mg PO or NG q 1-4h until end of symptoms or max 12mg/24h indicated for severe SS
148
Secondary effects of cyproheptadine
mydriasis urinary retention
149
Amanita toxicity
Phallotoxin acts first, causing nausea, vomiting, abdominal pain, and diarrhea. Fever, tachycardia, and hyperglycemia may also occur during this stage. The other toxin, amatoxin, causes renal tubular and hepatic necrosis.

PEM Lectures dirigées (28 decks)

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