Toxicology Flashcards
General Approach to Poisoned Pt.
- ABCDEs first
- deal with traumas
- get a good hx. what did thye take, how much, when & why!
Always assess your need for PPE: decontaminationg,etc.
- consider if pt. need external decontamination
- remove clothing; shower them
- apply own PEE
PE
- VS
- behavior and mental statu
- airway and breathing
- abd.
- skin
- neuro (tremor, ataxia?)
Labs
- based on the poison you suspect
- blood glucose
- EKG
- acetamin, salyciate, alchohol/ethanol
- other drug elvels
- UDS
what are toxidromes
Toxidromes = simialr toxic subtances have a constillation of symptoms and signs for hwo the pt. will present
anticholenergic
cholinergic
extrapyramindal
hallucinogenic
opiod
sedative
sympathomimmic
Anticholenergic Toxidrome
symptoms
substances
treatment
Symptoms
- tachycardia, fever, dry, dilated pupil (mydriasis), redness, urinary retention, delirum
- “blind as a bat, hot as hell, dry as a bone, red as a beet, mad as a hatter”
Substances
- antihistamines, TCAs, atropine, jimson weed
Treatment
- control their agitation: benzos
- consider giving: physostigmine (an acetylcholinesterase inhibitor)
- IV sodium bicarb for wide-complex tachycardia
Cholenergic Toxidrome
Symptoms
Substances
Treatmetn
Symptoms: think leaky!!!
- diarrhea, urination, miosis (pinpoint) brdaycardia, bronchorrhea, emisis, lacrimation, salivation
- SLUDGE: salivation, lacrimation, urination, dirrhea, gI, emesis
- seizures, twitching & weakness
Subtances
- pesticides: organophosmates & carbmates
- chemical warefare/terrorism
Treatment
- Atropine: an anticholenergic, give until the secretions improve
- Pralidoxime: reactiated acetylcholinesterase
- benzos: for the seizures
Extrapyramidal
Symptoms
Substances
Treatment
Symptoms
- dystonia, torticollis, muscle rigitiy, hyperreflexia, akathisia
Substances
- risperisone
- haloperidol
- phenothiazines
- metoclopramide
Treatment
- give diphenhydramine or benztropne
- seond line: give benzo
Hallucinogenic
symptoms
substances
treatment
Symptoms
- hallucinations, dyspphrai, anxiety, sympathomimetic signs (tachycardia, hypertension)
- nystagmus, agitation
Subtances
- pehncyclidine (PCP), Psilocybin mushrooms, Ketanine, Mescaline, LSD, dextamethrophan
Treatment
- benzos
- quiet dark room
- amde need sedative: haloperadol
Opioids Toxidrome
Symptoms
Subtances
Treatment
Symptoms
- drowsy
- pinpoint pupils
- respirtory depression
- brdaycardia
- hypotension
Substances
- fetanly
- heronin
- codeine
- oxycodone, hydroconde
- morphien
- methadone
Treatment
- Nalxone
- airway!!!
Sedative/Hypnotic Toxidrome
Symptoms
Substances
Treatment
Symptoms
- CNS depression, somnolence
- ataxia
- dysarthia
- bradycardia
- respiratory depression
Substances
- benzos
- barbituate
- alcohol
Treatment
- supportive care; watch airway
- avoid additional sedatives
Sympathomimetic Toxidrome
Symptoms
Substances
Treatment
Symptoms wet and sweaty
- agitation
- tachycardia
- diaphoresis
- hyperreflexia
- possible seiaures
- chest pain/ischmia
Subtacnes
- cocaine
- amphetamines
- cathiones
Treatment
- Benzos
- calm and treat agitation
Serotonin Syndrome/Toxicity
Symptoms
subtances
treatment
Symptoms
- AMS
- hyperreflexia and clonus
- tachycardia
- diaphoresis
- hypertension
- fever & flushing
- tremor
Subtances: serotonin
- SSRI, SNRI, TCA< MAO, cocanine, ampethamines, linezolid, lithum, triptans, detromethoraphan
Treatment
benzos
cyrpoheptadine
Neuroleptic Malignant Syndreom
Symptoms
Substances
Treatment
Symptoms
- lead-pipe muscule rigidity
- high temperature
- AMS
- diaphoersis
Substances
- antipsychotics
Treatment
- stop med & supportive care
- Benzos!
- muscle rigity: dantrolene or bromocriptine
Internal Decontaimination
Activated Charcol
Activated Charcoal
- wanted to give PO, and absorb the toxins in the GI tract
Indication
- would be ingested ideally within 1 hours
- need to weigh/risk beneift: not often used
COntraindications
- nontoxic ingestion, not abosrbed by AC (metals, corrosives, alcohol)
- cannot be used in unprotected airway pt.
Internal Decontamination
Gastric Lavage
Rationale
- removal of the toxin and aspiration
- rarely used
Indcations
- ingestion of life-threatening toxin within 1 hour
Contraindictaions
- do not do with corrosives or hydrocarbons: these are things you do NOT want the pt. to bring back up
- injury, aspiration complications
- unprotected airway
INteranl Decontamination
Whole Bowel Irrigation
Rationale
- give lots of polyethylene glycol (miralax) to help cleat it out
Indications
- sustained release toxins which cannot be absored by charcoal
COntraindications
- GI perforation
- vomiting
- airway
Opioids
- symptosm and signs
- overdose management
- withdrawal management
Opioids
- morphine, fetanyl, oxyodone, etc.
- will have opioid toxidrome: pinpoint pupils depressed breathing, bradycardia, etc.
Manangement
- always get a BS & do a PE
- may want to get UDS
Overdose
-give nalxone
Withdrawal
- check COWS score: clinical opiate withdrawal scale
- systemtic treatment: NSAID, ondansteron, etc.
- buprenorphine:partial agonis
- methadone: full agonists, from clinics
Ethanol
Symtoms and Signs
mangement
Ethanol: alcohol, but also mouthwash, hand sanitizer
Symptoms
- CNS depression, euphoria, slurred speech, ataxia
Management
- observe until metabolized out
- ask about treatment help
Methanol
symtpoms and signs
manamgnet
labs
Methanol: windshield wiper fluid, sternos
Symptoms
- typical “drunk” & visual symptoms
Labs
- check methanol levels, BMP for metabolic acidosis
- early on: osmolar gap, later: metabolic acidosis
Management
- fomepizole to block
- hemodyalysisif refractory metabolic acidosis
Ethylene Gylcol
Substances
Symptoms
Diagnostics
Management
Substance
-Anti-freeze
Symtpoms
alchol ntoxication + renal failure
Diagnostics
- check labs, BMP for anion gap, urine crystals
- early on = osmolar gap later= metabolic acidosis
Management
- Fomepizole
Isopropanol
Substances
Symptoms
Diagnosis
Treatment
Subtances
- rubbing alcohol
Symptoms
- alcohol intoxication + GI irritation
Diagnosis
- can chec labs
- ketosis without acidosis
Treatment
- supportive care
Benzodiazepines
Presentations
Diagnostics
Management
Benzos: lorazepam, alprazoalm, diazepam, etc.
(increases freqency of the channel opening)
Presentation
- CNS depression
- respiratory depression
Diagnosis
- get good histoyr
- check thier glucose!!!
Manangement
- supportive treatment wiht close monitoring
- may need to secure airway
- flumazenil: rarely used “narcan for benzos” but seizure risk
Barbituabtes
Symptoms
Diagnosis
Managment
Barbs: pehnobarbital, pentobarbital (increases duration of cholride channel open)
Symtpoms
- CNS depression
- WORSE respraory depression (than benzos)
Diagnosis
good history and check glucose
Manangment
- supportive
- watch airawy
Acetaminophen
Presentation
Diagnosis
graph
treatment
Presentation (tylenol)
- large dose = liver faiulre
Presentation
- early on = no sx.
- later: N/V abd. discomfort
Diagnosis
- get acetaminophen labs, CMP
Treatment
- the rumack-matthew nomogram: determines amoutn of acetominophen in the body & when to treat
- below line = no treatment needed
- above the line: treat n-acetylycystine
NSAIDS
presentation
diagnosis
treatment
Presentation
- ibuprofen, naproxen, ketolac
- well tolerate but high doses abd pain, N/V, HA, dizzy
- coma, apnea, metabolic acidosis, death = if massive doses
Diagnosis
- get acetominophen & salicylate level
Treatment
- supportive care
- massive overdse (400mg/kg) = gastric lavage or charocoal
SSRIs
presentation
diagnosis
treatment
PResentaiotn
- nausea, vomiting, sedation, tremor , tacycardia
- possible QRS/QTc prolong. (rare)
- watch serotonin syndrome
Diagnosis
- EKG
Treatment
- supportive moniotr 6 hours
TCAs
presentation
diagnosis
treatment
TCA PResentation
- cardiotoxicity is the big risk here
- antichlenergic toxidrome
- sedation/AMS
- hypotension
- symptoms will occur within 6 hours
Diagnosis
- EKG
- glucose
- UDS
Managemnet
- monitor for 6 hours
- consider charcoal if its been within 1hour of ingestion
- Sodium Bicarbonate if abnoraml EKG (get pH 7/5-7/55)
- seizures: give benzo
- hypotension: give norepi.
Salicylates
Presentation
Diagnosis
Treatmetn
Saicylates
- asprin
- oil of wintergreen
Presentation
- mild: hearing loss, dizzy, N/V
- moderate: tacypnea, sweating, ataxia
- severe: AMS, seizure, renal failure, arrythmias
Diagnosis
- metabolic panel. blood gas, EKG , urine
- salcylate level serially
- watchrespiratory alkalosis, metabolic acidosis with gap
Treatment
- consider active charocoal if within the 1 hour
- whole bowel irrigation
- IV fluids
- monitor and seiral salyciate levels
- sodium bicarb drip to help
- dialysis if nonresponding
Lithum
Presentaion
Diagnosis
Treatment
Lithuim: bipoalr treatment
Presentation
- acute toxicity: GI N/V/D & volume depletion
- Chronic: CNS side effectts, confusion, hallucinations, seizures
- can have cardaic effects
Diagnosis
- metabolic panel
- get lithum levels: but levels DO NOT predict outcomes
Treatmen t
- stop the med and supportive care
- seizure: benzos
- if gettign worse: dialysis
Alcohol Withdrawal
timeline
6-24 hours
6-60 hours
12-48 hours
48-96 hours
Alcohol Withdrawal
6-24 hours:
- anxiety, N/V, palpations, tremor & headache
- doest worsennow? theyll recover
6-60 hours:
- risk fo withdrawl seizures occurs
12-48 hours:
- hallucinations
48-96 hours:
- Delirium Tremens
Alcohol Withdrawl
DT
what is it & presentaion
diagnosis
treatment
DT:
- acute and fluctaiong distrubacnes in cogntion related to alcohol
- mortality high wihtout treatment
Presentation
- confusion, agitation, inattention, hallucinations
- autonotmic overacticity: fever, tacyhcardia, hypertension)
- fluid and electrolyte imbalances
Diagnosis
- check CML, glucose, alcohol labs
- get CIWA score
Treatment
-HEAFY benzo use IVe 20-30 minutes
if not respoding, give barbital, propofol and intubate and ICU
Wernicke’s Encephalopathy
neruo complications due to chronic alcohol use
- thamin (vtiB1) is a cofactor needed
Presention
- confusion
- ataxia
- oculomotor abnormalities
Management
- give IV thiamine
- and give dextrose
