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1. Fellowship Written - SAQ > Toxicology > Flashcards

Toxicology Flashcards

1
Q

What are the main clinical features of large acute lithium OD

A

mainly GI
under 25g mild, over 25 mod to severe
neurotox rare

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2
Q

What are the main clinical features of chronic lithium toxicity

A

Neurotoxic:
Grade 1 = tremor, agitation, hyper-reflexia, ataxia
* Grade 2 = stupor, rigidity, hypotension
* Grade 3 = coma, seizures, myoclonus

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3
Q

name three factors that predispose to chronic lithium toxicity

A

impaired kidney function
diabetis insipidus
dehydration
sodium depletion
drug interactions eg NSAIDS

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4
Q

What is the modality for lithium enhanced elimination?
What are the indications?

A

haemodyalsis

Indications;
renal impairement
serum lithium >2.5
established neurotoxicity

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5
Q

What agents may increase chance of heat stroke?

What are the methods for rapidly cooling?

A

MDMA
diuretics
salicylates
anticholinergic agents

Cooling:
Evaporative cooling eg spray and fan
ice packs to groin an axilla
arctic sun

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6
Q

list some conditions and clinical findings linked to alcohol abuse

A
  • Acute alcohol withdrawal – tremor, tachycardia, fever, seizures
  • Wernicke’s encephalopathy – nystagmus, confusion, ataxia
  • Peripheral neuropathy – stocking style sensory loss, loss ankle jerk
  • Cerebellar degeneration – dysdiadochokinesis, nystagmus, ataxia, past pointing etc
  • Several others OK eg alcoholic hepatitis, pancreatitis, gastritis
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7
Q

what is the toxic dose of amitryptiline?

A

over 10mg/kg life threatening
over 30 severe effects

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8
Q

what are the toxic effects of anticholinergics

A
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9
Q

what is the key investigations in TCA overdose

A

**ECG **
to look for QRS widening due to sodium channel blockade
* QRS over 100 seizures
* QRS over 160 VT

Other
paracetamol
VBG
renal function

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10
Q

how do you treat a TCA overdose seizure with end points

A
  • sodium bicarb 1-2mmol/kg IV, then midazolam to terminate seizure
  • Check ECG - if QRS widening for 8.4% sodium bicarb to reduce QRS
  • early intubation to avoid come due to respiratory acidosis - mention drugs
  • settings - tv 6-8ml/kg, hyperventilate 7.5-7.55, PEEP 5
  • fluids
  • activated charcoal if large ingestion
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11
Q

Summary of toxidromes

A
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12
Q

what is the toxic dose of two main calcium channer blocks

What is the mechanism of toxicity?

A

Verapamil and diltizaem both over 10 tablets. 1 or 2 in children

Mechanism

  • vasodilates and negatively ionotropic and chronotropic by stopping opening of L type calcium channels decreasing cellular contractility
  • Also impairs insulin release
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13
Q

management steps for calcium channel blocker OD causing significant brady cardia

A
  • ABCDE
  • IF fluid boluses
  • 10-20ml boluses of calcium cl
  • adrenaline or noradrenaline
  • high does insulin dextrose - bolus 50ml 50% dextrose plus 0.5-1 unit/kg - then infusion
  • monitor BSL and mg and K
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14
Q

why insulin dextrose in calcium channel blocker OD

A

overcomes metabolic starvation in the heart to increase output

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15
Q

diagnosis and pathophysiology

acute management?

A

Methaemoglobinaemia

fe2 changes to fe3 so haemaglobin becomes methaaemoglobin
reduces oxygen carrying capacity and does not give up what it has

Management
o2 via NRM
remove causatie agent
methyline blue 1mg/kg iver 5 mins with repeated doses if needed

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16
Q

what agents can cause Methaemoglobinaemia

A

prilocaine
dapsone
chlroquine
GTN
Nitrates
Nitrites

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17
Q

what factors can increase chance of toxicity with calcium channel blockers

A

agent - verap and dilt the worst
dose
co-ingestion other cardiac meds
extremes of age
co-morbitidies

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18
Q

features of calcium channel toxicity

A

bradycardia
hypotension
hyperglycaema
pulmonary oedema
lactic acidosis
seizures

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19
Q

what is the lethal dose of digoxin?

A

over 10 mg in adult or 4 in child
or over 10x daily dose

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20
Q

what are the features of acute dog toxicity

A

**GI **- nausea and vomiting
**CNS **- lethargy, confusion, delirium
**CVS **- bradycardia, heart blocks, slow AF, VT, SVT

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21
Q

what are the indications for digibind?
What is the dose

A

Indications
* cardiac arrest
* life thretening aryhtmia
* lethal dose (over 10mg adult and 4mg child)
* K over 5
* dig level over 15

Dose
5 or 10 ampoules

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22
Q

what are the clinical effects of eucalyptus oil ingestion?

A

CNS depression - LOC/seizures
**Respiratory **- aspiration and aspiration pnemonitis, cough, choking
**GI **upset - nausea and vomiting and oral irritation
**CVS **- tachy and hypotension

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23
Q

what is the management of eucalyptus oil ingestion?

A

supportive care - intubate and ventilate to protect aiway as needed
observe
monitor electrolytes and BP - fluid if needed
consult tox
admit
no role for antidoes or decontamination

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24
Q

What are the key things in a tox risk assessment

A
  • agent
  • dose
  • co-ingestion
  • time of ingestion
  • co-morbidities
  • clinical features
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25
Q
A

**infections **- meningitis/encephalitis
**toxidrome **- serotonin syndrome, anti cholinergic syndrome, NMS, sympathomimentic toxicity
**endocrine **- thyroid storm
enviromental- heat stroke
delirium tremens
**CNS **- stroke

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26
Q

What is the Hunter Serotonin toxicity Criteria?

A

must have a seritonergic agent in their system plus at least one of the following;

  • spontenous clonus
  • inducible clonus and agitation/diaphoresis
  • ocular clonus and agitation/diaphroresis
  • tremor and hypereflexia
  • hypertonia and tremor
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27
Q
A
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28
Q

relevant features of history post insulin overdose and how it is relevant to management

A
  1. type of insulin - will affect duration of toxicity and observation
  2. amount - severity of toxicity
  3. multiple sites or one site - one site longer duration of action
  4. diabetic or not - dictates how you ween glucose infusion
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29
Q

for insulin OD what are the treatments

A

IV dextrose infusion aiming BSL over 35
IV K aim for normal range

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30
Q
A
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31
Q
A
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32
Q

what are three methods of decontamination used in iron OD and when they would be used

A
  • WBI on over 60mg/kg
  • surgical or endoscopic removal over 120mg/kg
  • Gastric lavage via ETT and witing 90 mins ingestion
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33
Q

what is the drug and dose for iron chellation?

A

Desferrioxamine IV. 15-40 mg/kg/hr

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34
Q
A
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35
Q

iron overdose, List two relevant findings and how it may alter management

A

RUZ consildation with no evidence of iron in GI tract

no need for WBI - may need bronc

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36
Q

what bloods may you order in suspected iron OD

A

serum iron levels 4-6 hours post
VBG for lactate and acid base disturbance
coags - liver involvement
BSL - hypo or hyperglycaemia
U+E - renal involvement
FBC - leucocytosis or thrombocytopenia

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37
Q

Rate
Rhythm
Axis

Main abnormality?
Why does this happen

A

sinus
75
normal

Qt prolongation
K channel blockade

38
Q

common agents for QT prolongation

A

The anti

Antibiotics - cipro, clarithro
Antidepressants - SSRI, TCA, lithium
antipsychotics - haloperidol, chlorpromazine
antihistamines - loratidine

39
Q

Examination features of SSRI toxidrome

A
40
Q

Outline the initial management of hyponaetremia and the next day - it is an acute change

A

bolus 100ml 3%HTS and repeat if still seizing or airway risk
aim 6-12mmol increase in 24 hours
HDU/ICU management

41
Q

main features

What illicit drugs can cause this?

Treatment?

A

widespread st elevation
narrow complex tachy
depression avr

Drugs
* sympathomimetic eg cocaine, ecstasy
* LSD
* volatile agents

Treatment
IV benzos
calm environment
GTN infusion
?thorombolytics

42
Q

what underlying condition can predispose you to methaglobulinaemia

A

G6PD

43
Q

what is the dose of activated charcoal

A

50g
1g/kg in paeds

44
Q

what are the contraindications for activated charcoal

A

active resus
aspiration risk
charcoal wont bind eg metal
benign agent
sub toxic dose
too long since ingestion

45
Q

what are the features of significant carbamazepine overdose

A

anti cholinergic effects
CNS - LOC, seizure, ataxia, nystagmus
CVS - hypotension, tachy or brady arrthymia, prolonged PR, QRS, QT

46
Q

With any drug related seizure, wht should be ruled out?

A

hypoglycaemia
eclampia
infection
hyponaetramia
co-ingestion
ICH

47
Q

relevant findings
reduced GCS
drowsy

A

prolonged PR
broad QRS
RAD

48
Q

propanolol
life threatening effects of OD and the management

A
  • Coma - airway protection
  • seizures - benzos
  • brady/hypotension - atropine, adrenaline, noradrenaline
  • sodium channel blockade - bicarb
49
Q

OD low GCS
ECG findings

what drugs tend to do this?

A

broad QRS
RAD
prolonged QT

TCA

50
Q

list the abnormalities and reason why

What is the most likely clinical scenario

A

Severe hyperkalaemia – cellular shift due to metabolic acidosis, renal failure, cell death with rhabdo

High anion gap metabolic acidosis – renal failure, lactic acidosis lost likely

Renal failure – urea/creat less than 100 – suggests intrinsic renal failure – most likely due to rhabdo

scenario - rhabdo from long period on floor post sedation

51
Q

is there a role for decontamination in liquid paracetamol?

what is the threshold for liquid paracetamol and when should you measure level?

n

A

no - absorption is too quick

200mg/kg of liquid - 2 hours

52
Q

what are the one pill killers for kids?

A

verpamil
diltiazem
sodium channel blocks eg TCA
opiates
gliclazide
theophylline

53
Q

what are the steps when someone gets an anaphylactoid rash with NAC

A

stop
bronchodilator if wheezy
anti histmiane
pred 1mg/kg
start at slower rate

54
Q

what are the indications for activated charcoal in paracetamol OD

A

within 2 hours for immediate release
within 4 hours for sustined release
massive (over 30gm) within 24 hours

55
Q

what is the criteria for cessation of NAC

A

if non toxic - repeat paracetmol below line and falling

if toxic - NAC complete and ALT less than 50 and paracetamol less than 10

56
Q

what are the criteria for transfer to liver unit post paracetamol OD

A

INR > 3.0 at 48 hours or > 4.5 at any time
* oliguria or creatinine > 200 mmol/L
* persistent acidosis (pH < 7.3) or arterial lactate > 3 mmol/L
* systolic hypotension with BP <80 mmHg, despite resuscitation
* hypoglycaemia
* severe thrombocytopenia
* encephalopathy of any degree, or ALOC (GCS < 15) in the absence of sedatives

57
Q

descrive

A

Interventricular conduction delay- QRS > 100msec
Terminal R wave > 3mm in aVR and R/S ratio > 0.7 in aVR
Tachycardic rate ~110, sinus rhythm- p waves in T waves- best seen in V1, R axis deviation

58
Q

what is a terminal R wave in v3 suggetive of?

A

TCA overdose

59
Q
A
  1. Taken multiple serotonergic medications – risk of serotonin syndrome
  2. Multiple medications that may cause sedation – ALOC/need for airway protection
  3. tCA overdose >30mg/kg – associated with severe toxicity
  4. Paracetamol potential toxic dose ie >10g, or >150mg/kg
60
Q

risk assessment

A

large ingestion of lethal agent
GCS already 14
alreasy showing biochemical signs

61
Q

what are the decontamination methods for K OD

Pro and con for each

A

WBI - good because quikcer then dialysing, hard becuase need intubation and staff to manage this
dialysis - good because definitive but invasise

62
Q
A
63
Q

differentials for methaglobulinaemia with prilocane

what is definitive test?

treatment options

A

anaphylaxis
seizure
VT

Test - ABG for saturation gap - pa02 v sats

methyline blue
high flow o2
HBOT
vitamin C
NAC

64
Q
A

HAGMA with respiratory alkalosis

WINTERS = Expected Co2 = 1.5 x HCO3 +7 +/- (accept 3) -

65
Q

what blood gas features are most consistent with toxic alcohol ingestion?

A

high lactate
high osmolar gap
high lactate gap

66
Q

what are the important investigations with ?toxic alcohol ingestion and why

A
67
Q

what are the treatments for toxic alcohol overdose

A
68
Q

what are the clinical features of salicylate toxicity?

A
  • initial hyperventilation
  • tinnitus
  • nausea
  • vimiting
  • dehydration
  • pyrexia
  • confusion
  • dehydration
69
Q

for salicylate OD

A
70
Q

what drugs can be used to manage serotonin syndrome

A

benzos

serotonin agonists - olanzapine, chlorpromazine

71
Q

drugs that cause serotonin syndrome

A

Antidepressants:
MAOIs - any
SSRIs - any
SNRIs - any
TCAs - any

Opioids – tramadol, buprenorphine

Anticonvulsants (Valproate, Carbamazepine)

5-HT3 antagonists - ondansetron
Metoclopramide

Lithium

Amphetamines

Antibiotics – ciprofloxacin, erythromycin

72
Q

what conditions need to be met to remove snakebite pressure bandage

A

No clinical signs of envenoming
No lab signs of envenoming
Patient in monitored, witnessed area
Local access to antivenom

73
Q

description

A

ptosis
pupil down and out

third nerve palsy

death adder
tiger
taipan

74
Q

Low GCS
interpret and list tox causes

A

HAGMA

Causes
Cyanide
o Isoniazid, Iron
o Alcohol (ethylene glycol, methanol, propylene glycol)
o Salicylates
o Valproate
o Paraldehyde

75
Q

what are the signs and symptoms of cyanide toxicity

A
76
Q

treatment for cyanide toxicity

A
77
Q

what paralytic is unsafe in hyperthermic patient?

A

sux

78
Q

unresponsive after femoral nerve block with bupivicanine
What do you do?

what are specific antidotes?

A

stop injection
begin CPR as per aLS
support airway and oxygenate

antidotes
intralipid 20% 1-1.5ml/kg every 3 minutes then infusion

79
Q

what is the safe dose of bupivicaine
ropivicane
lidocaine

A

2.5mg/kg
3.5mg/kg
3mg/kg

80
Q

causes of tachycardia post intubation and historical feature

A
81
Q

four important complications of GHB overdose

A

coma
agitation
fluctuation consciouness
hypotension
aspiration
secondary injuries

82
Q

what are the indications for intubation with GHB

A
  • cant maintain away
  • hypoventilation
  • extreme agitaiton
  • resp failure
  • aspiraiton
  • concern for head injury
83
Q
A
84
Q

why may ETc02 be high after intubating?

A

1) Increased CO2 production – fever, thyrotoxicosis
2) Increased pulmonary perfusion – High CO, hypertension
3) Poor alveolar ventilation – hypoventilation, bronchial intubation
4) Technical mechanical errors – leak or faulty valve

85
Q

key features
causes

A

features
AF
ventricular rate 65
wide QRS
right axis

causes
dig
hyperK
ischaemia
TCA
beta blockade

86
Q

key in benztropine OD

A

no sweating

87
Q
A
88
Q

features of meth intoxication

A

Agitation/Anxiety/ Hypervigilence
Paranoia/Hallucinations
Psychomotor agitation – restlessness, tremor
Pressured speech
Sweating, flushed skin
Teeth Grinding, Jaw clenching
Mydriasis
Hypertension
Tachycardia

89
Q

what are the indications for haemodialysis in toxic alcohol ingestion

A

large ingestion with osmolar gap over 10
PH less than 7.3
renal failure
clinical deterioration

90
Q
A
91
Q

dose dependant clinical features of olanzapine OD

A

1. Fellowship Written - SAQ (27 decks)

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