Toxicology

Question 1

Serotonin syndrome medications

Answer 1

SSRIs
Opiates eg tramadol fentanyl
SNRIs eg venlafaxine
TCAs eg amitriptyline
MAOI eg meclobamide
Antipsychotics eg quetiapine
Recreational drugs eg MDMA
Herbals eg St John’s Wort
Antiemetics eg ondansetron
Mood stabilisers eg valproate, lithium

Question 2

Serotonin syndrome signs

Answer 2

CAN
CNS - hypo or hyper, seizures
Autonomic dysfunction - hypo or hypertension, tachycardia or bradycardia, hyperthermia, dysrhythmia, flushing, sweating, midriasis
Neuromuscular - hyperreflexia, rigidity, tremor, clonus, myoclonus

Question 3

Serotonin syndrome complications

Answer 3

Seizures, rhabdomyolysis, metabolic acidosis, renal failure, ARDS, DIC, coma, death

Question 4

NMS drugs

Answer 4

Haloperidol
Chlorpromazine
Clozapine
Risperidone
Abrupt withdrawal of Parkinson’s meds

Question 5

NMS sx and signs

Answer 5

Highly variable
Presentation can be up to 10 days from precipitant, or longer
Hyperthermia and muscle rigidity
Tachycardia
Labile BP
Altered mental status
Parkinsonism
Incontinence
Diaphoresis
Excess salivation

Question 6

NMS complications

Answer 6

AKI
Cardiac arrest
Respiratory arrest
Rhabdomyolysis
DIC
Coma
Death

Question 7

Alcohol abuse definition

Answer 7

Maladaptive drinking behaviour causing clinically significant distress or impairment of social or occupational functioning.
Maladaptive can be daily or binge drinking
Impairment can be:
-social eg fights with partner/family
-legal eg arrests
-occupational eg not attending work or fulfilling obligations
-or physical hazards eg operating car/machinery

Question 8

Alcohol abuse assessment

Answer 8

Ask
Brief advice
-W= 2SD/day, 4 max, 10/wk
-M = 3SD/day, 5max, 15/wk
-2x AFD/wk
Counselling (offer)
AUDIT-C
-how often drink last year?
-how many drinks per occasion last year?
-how often more than 6?

Question 9

Alcohol dependence assessment

Answer 9

Maladaptive drinking causing distress with 3 or more of:
Tolerance
-needing more for same effect
-reduced effect of current use
Withdrawal
-tremors
-agitation/agitation
-N/V
-sweating and elevated HR
-hallucinations
-seizures
More than intended ingestion
Unsuccessful attempts to reduce/stop
Lots of time using/obtaining/recovering
Reduced activities
Persistence despite adverse effects

Question 10

Carbon Monoxide history

Answer 10

COMA
Co-habitants - are they also unwell?
Outside - do you feel better outside?
Maintenance - are your CO-emitting devices well maintained?
Alarm - do you have one?

Question 11

Carbon monoxide symptoms

Answer 11

HA
Nausea/vomiting
Chest pain
Abdo pain
Neuro sx
Lethargy
SOB

If chronic:
-ataxia, uncoordination, memory issues, tremors, fatigue, hearing loss, mood change

Question 12

Carbon monoxide exam

Answer 12

ABC
Obs
Full neuro exam
BSL
Cherry red lips
NOTE O2 SATS MAY BE NORMAL as CO reads as O2

Question 13

Organophosphate poisoning

Answer 13

Nicotinic effects MTWTF
Mydriasis
Tachycardia
Weakness
hyperTension
Fasciculations
Muscarinic effects occur later and are more classic:
Diarrhoea
Urination
Miosis
Bronchospasm
Emesis
Lacrimation
Sweating
Other effects include:
Confusion
Hallucinations
Anxiety
Drowsiness
Emotional lability
Seizures
Insomnia
Memory loss
Circulatory, CNS or respiratory depression. Check eyes for exposure and may need to flush

Question 14

Organophosphates - long term sequelae

Answer 14

Peripheral neuropathy - glove and stocking, can lead to flaccid paralysis from lower to upper

Question 15

Organophsphate poisoning - treatment

Answer 15

PPE
Destroy clothes of affected
Atropine
IV fluids
Benzos

Question 16

Salicylate poisoning signs

Answer 16

Mild (3-8 hours)
-nausea/vomiting/abdo pain
-dizziness
-tinnitus
-tachypnoea
-HA
Moderate (6-18 hours)
-confusion
-slurred speech
-hallucinations
-tachypnoea more pronounced
-hypotension
-tachycardia
-respiratory alkalosis
-hypoglycaemia
Severe (12-24 hours)
-cerebral and pulmonary oedema
-hypoventilation
-obtundation
-seizures
-hypotension
-dysrhythmia
-metabolic acidosis

Question 17

TCA effects

Answer 17

TCAs have multiple effects:
-Serotonin transporter (SERT) inhibitor and Noradrenaline transporter (NET) inhibitor
-profound alpha-adrenergic blocker
-antihistamine and anticholinergic effects
-sodium channel blockade and L-type calcium channel blockade leads to cardiotoxicity
-5HT agonism
-dopamine reuptake inhibition
-NMDA agonism
-sigma opiate receptor agonism

Question 18

TCA overdose

Answer 18

CNS effects
-confusion, decreased GCS, seizures, respiratory depression, tremor, clonus
Cardiac effects
-prolonged QRS, dysrhythmia, tachycardia, hypotension
-anticholinergic effects eg dry mouth, tachycardia, flushed skin, urinary retention
Metabolic acidosis

Question 19

Lithium toxicity cause and symptoms

Answer 19

Commonly with new or increased Rx or if volume or sodium depletion eg gastroenteritis, sweating, exercise, CHF
AMS
Drowsiness
Nausea/vomiting/Diarrhoea
Tremor
Weakness
Ataxia

Severe:
Hypotension
Dysrhythmia
Seizures
Coma
Death

Question 20

Lithium toxicity ECG findings

Answer 20

T wave flattening -can occur normally with lithium
Sinus node dysfunction (#1)
QT prolongation
QRS prolongation
U waves