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toxicology Flashcards

1
Q

what are general measures needed in suspected OD/ poisoning?

A
  1. ABCDE assess
  2. History: symptoms, PHMx, why, Risk assess
  3. Basic obs
  4. Specific systems examined
  5. Weight
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2
Q

what general investigations are needed in OD/ poisoning?

A
  • Bloods: FBC, LFT, U&Es, clotting, glucose, CK
  • Blood gas
  • Specific drug plasma conc (4hrs for paracetamol), urine toxicology
  • CXR
  • ECG: cardiac conduction
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3
Q

give some examples of anticholinergics?

A

Atropine
Antihistamines

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4
Q

how would anticholinergic poisoning present?

A

high HR
high BP
high temp
dilated pupils
no bowel sounds
dry

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5
Q

name some cholinergic?

A

Organic phosphorus
Mushrooms
pilocarpine

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6
Q

name some signs of cholinergic excess?

A

pinpoint pupils
loud bowel sounds
moist

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7
Q

name some opioids?

A

Morphine
Codeine
Tramadol
Heroin
Methadone
Hydrocodone
fentanyl

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8
Q

how would opioid OD present?

A

low HR
low BP
resp depression
cold
pinpoint pupils
no bowel sounds
dry

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9
Q

name some sympathomimetic drugs?

A

Caffeine
Cocaine
Amphetamines
MDMA
Theophylline

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10
Q

how would sympathomimetic OD present?

A

tachycardiac
hypertensive
high RR
warm
diklated pupils
loud bowel sounds
dry

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11
Q

name some sedative-hypnotics?

A

Anti-anxiety agents
Muscle relaxants
Benzos
Barbiturates

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12
Q

how would sedative-hypnotic OD present?

A

low HR
low BP
low RR
cold
no bowel sounds
dry

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13
Q

what questions are needed within paracetamol OD?

A
  • Timing
  • Staggered/ non staggered
  • How many tablets  workout mg/kg (500mg a tablet)
  • Other enzyme inducing drugs/ low BMI/ anorexia/ malnutrition  higher risk of hepatoxicity
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14
Q

how would paracetamol OD present within first few hrs?

A

N+V, abdo pain

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15
Q

how would untreated paracetamol OD present?

A

: vomiting continuing for 12hrs, pain/ tender liver from 24hrs, jaundice (2-3days), hepatic encephalopathy (3-5days)
- Loin pain, haematuria, proteinuria  renal failure
- Hepatic failure causes bleeding from coagulation abnormalities , hyperventilation  metabolic acidosis

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16
Q

when would LFTs become deranged within paracetamol OD?

A

> 18hrs after OD

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17
Q

what occurs within paracetamol toxicity?

A

uses the toxic pathway
glutathione can not keep up
causes hepatotoxicity

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18
Q

what can cause glutathione depletion?

A
  • Malnourished: eg dental pain causing to not eat, fasting more than 1 day
  • Eating disorders
  • Failure to thrive or CF in paeds
  • AIDS
  • Cachexia
  • Alcoholism
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19
Q

name some enzyme inhibitors?

A

S- sodium valproate
I – isoniazid
C- cimetidine
K- ketoconazole
F- fluconazole
A - Alcohol binge
C- chloramphenicol
E- erthyromycin
S: sulfonamides
C- ciprofloxin
M- metronidazole

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20
Q

name some enzyme inducers?

A

S: sulphonylureas
C: carbamazepine
R: rifampin
A: alcohol
P: phenytoin
G: grisofulvin
P: Phenybarbital

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21
Q

what is classed as acute paracetamol OD?

A

Excess amount of paracetamol
Ingested all in <1hr
Usually self harm

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22
Q

what is classes after staggered OD

A

Excess paracetamol ingested >1hr
Usually self harm

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23
Q

what is classed as therapeutic excess?

A

Excess paracetamol
Intent to treat pain/ fever
No intent of self harm
Elderly – misreading labels
Dental pain- couldn’t manage pain and took extra

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24
Q

how do you manage acute paracetamol OD that presents <8hrs?

A

Wait 4hrs from ingestion  take blood sample
Start acetylcysteine if 4hr plasma above line
Start acetylcysteine if evidence of hepatoxicity

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25
what is management of acute OD -para presenting 8.12hrs?
Blood samples immediately If ≥150mg/kg: start acetylcysteine or symptomatic and waiting blood samples If <150mg/kg: wait results and then decide
26
how do you manage acute OD -para, pres more than 24hrs
Blood samples immediately If ≥150mg/kg: start acetylcysteine or symptomatic and waiting blood samples If <150mg/kg: wait results and then decide – check INR
27
how would you manage staggered para OD?
Start acetylcysteine immediately Take blood samples 4hrs after last ingestion Stop acetylcysteine if low risk of hepatotoxicity
28
how would you manage therapeutic excess OD?
If symptomatic: start acetylcysteine Manage therapeutic excess depending on pt weight, quantity consumed
29
how would you manage a super acute - all ingested and presented within 1hr?
Activated charcoal Check blood samples after 4hrs of last ingesting and decide
30
how does acetylcysteine work?
- Can help with repair of damaged tissues
31
what can occur within acetylcysteine infusion?
- Infusion reaction: anaphylaxis risk, itchy, syncope, drop in BP
32
what is the SNAP protocol?
- Parvolex given IV with 5% glucose - SNAP protocol: 100mg/kg in 200ml over 2hrs and then 200mg in 1000ml over 10hrs (12hrs in total)
33
what are signs would indicate benzo OD?
low GCS, ataxia, dysarthria, resp depression
34
how do you manage a Benzo OD?
Flumazenil – 0.5mg IV  indicated in resp depression, caution if dependent due to withdrawal and seizures
35
why should you be cautious with flumazenil?
lots of side effects
36
what cardiac signs indicate beta blocker OD?
QRS widening, hypotension, sinus bradycardia, 1st-3rd AV block, VF/VT
37
what CNS signs can be seen with beta blocker OD?
drowsiness, confusion, convulsions, coma, absence of pupil reactivity
38
apart from cns and cardiac effects, what else can be seen with beta blocker OD?
: bronchospasm, pulmonary oedema and hyperkalaemia
39
how do you manage beta blocker OD?
Glucagon: severe hypotension, HF, cardiogenic shock unresponsive to atropine - Bolus of 5-10mg IV injection administered in glucose %% over 1-3mins then reduce down
40
what side effects can glucagon do when managing BB OD?
- Side effects: N+V, hyperglycaemia, hypokalaemia, hypocalcaemia
41
if glucagon fails when managing BB OD, what can be used as next lines?
Use atropine and pacing if needed
42
what mmol/L is classes as lithium poisoning?
>1.5
43
what can cause lithium toxicity?
- Causes of dehydration/ renal impairment make it more likely - NSAIDs, diuretics, ACE-I can make worse
44
what are signs of lithium toxicity?
- Nephrogenic diabetes insipidus  polyuria and polydipsia - Hypothyroidism - N+V - Fine tremor, dysarthria and ataxia - Sweating - Seizures and coma - Weight gain – increases appetite
45
how can you manage lithium toxicity?
- Forced diuresis: N.saline to enhance elimination - Omit drugs: monitor levels  caution to not go to low as can cause bipolar relapse - Haemodialysis: severe features of toxicity  neuro symptoms, seizures and coma
46
which drugs have narrow therapeutic ranges?
- Digoxin - Theophylline - Lithium - Phenytoin - Gentamicin - Vancomycin - Tobramycin
47
what drugs interact with warfarin and increase INR?
Amiodarone Ciprofloxacin Fluconazole Macrolides Isoniazid Ethanol (acute) Cimetidine Omeprazole Cranberry juice diarrhoea
48
what interacts with warfarin and can lower INR?
Rifampcin Carbamazepine Phenytoin Phenobarbital St Johns wort Cigarette smoking Ethanol – chronic Food high in vitK
49
what are mild signs of CO poisoning?
slight headache, N+V, fatigue
50
what are signs of moderate CO poisonings?
severe headache, confusion, drowsiness, tachycardiac
51
what are signs of severe CO poisoning?
: unconsciousness, convulsions, cardio-resp failure, death
52
how do you manage CO poisoning?
- Remove source of CO - High flow O2 with tight fitting mask – 15L non-breather - Intubation - Hyperbaric Oxygen  unconscious or >40%COhb or 20% and pregnant - Other supportive therapy
53
what are CNS signs of amitriptyline OD?
: extreme drowsiness, confusion, sensation of being hot then very cold, muscle stiffness, seizures, fainting, coma
54
what are eye and mouth signs of amitriptyline OD?
blurred vision, dilated pupils, eye pain, dry mouth
55
what happens to RR in amitriptyline OD?
slow RR
56
what happens to renal/ urinary system in amitriptyline OD?
difficulty to urinate, not proper flow of urine
57
what happens to cardiac system in amitriptyline OD?
irregular pulse, slow pulse, low BP, shock
58
what are general signs of TCA OD?
TCA OD: can cause hyperreflexia, metabolic acidosis - cardio-resp depression
59
how do you manage amitriptyline OD?
sodium bicarb if at risk of arrhythmia and seizure
60
what are signs of SSRI OD?
serotonin syndrome SHIVERS : Shivers, Hyperreflexia and myoclonus, Increased temp, Vital sign abnormalities, Encephalopathy, Restlessness, Sweating
61
what is the warfarin antidote?
VitK - situ dependent
62
what is digoxin antidote?
Digoxin specific AB if cardiac output is impaired digifab
63
what is apixaban/ rivaroxaban antidote?
Andexanet alfa Specific reversal for factor Xa inhib Usually for life threatening/ uncontrolled GI bleed and on apixaban
64
what is nitrous oxide antidote?
Hydroxocabalamin 1mg IM STAT
65
what is antifreeze?
ethylene glycol
66
how would someone who drank antifreeze - ethylene glycol present?
May seem drunk with occasional haematemsis
67
what is the management of antifreeze/ ethylene glycol OD?
Fomepizole
68
what is the moa of fomepizole?
Competitive inhib of alcohol dehydrogenase Used to reduce production of toxic metabolites
69
how do you manage mild-moder cyanide poisoning?
hydroxocobalamin
70
how do you manage severe cyanide OD?
thiopental sodium Oxygen, dicobalt edetate, sodium nitrate
71
what is the medical platform for posoining guidance?
toxbase
72
how do you manage iron OD?
desferrioaxamine
73
how do you manage organophosphorus OD?
Atropine Pralidoxime
74
how might iron poisoning present?
N+V and abdo pain initially - can improve and then deteriorate again - diarrhoea and haematemesis - GI disorder
75

Mental Health (4 decks)

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