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1. Fellowship Written - SAQ > Toxicology > Flashcards

Toxicology Flashcards

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1
Q

What are the main clinical features of large acute lithium OD

A

mainly GI - nausea, vomiting, and pain and diarrhoea
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

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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 8.4% 1-2ml/kg IV, until seizure stops or qrs under 100 then midazolam to terminate seizure
  • Check ECG - if QRS widening for 8.4% sodium bicarb to reduce QRS
  • early intubation to avoid coma 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

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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12
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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13
Q

why insulin dextrose in calcium channel blocker OD

A

overcomes metabolic starvation in the heart to increase output

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14
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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15
Q

what agents can cause Methaemoglobinaemia

A

prilocaine
dapsone
chlroquine
GTN

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16
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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17
Q

features of calcium channel toxicity

A

bradycardia
hypotension
hyperglycaema
pulmonary oedema
lactic acidosis
seizures

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18
Q

what is the lethal dose of digoxin?

A

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

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19
Q

what are the features of acute dig toxicity

A

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

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20
Q

what are the indications for digibind?
What is the dose

A

Indications
* cardiac arrest
* life threatening arythymia
* lethal dose (over 10mg adult and 4mg child)
* K over 5.5
* dig level over 15

FIVE TEN FIFTEEN

Dose
5 or 10 ampoules

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21
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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22
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
  • consult tox
  • admit
  • no role for antidoes or decontamination
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23
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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24
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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25
relevant features of history post insulin overdose and how it is relevant to management
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
26
for insulin OD what are the treatments
IV dextrose infusion aiming BSL over 3.5 IV K aim for normal range 10-50%dextrose
27
28
29
what are three methods of decontamination used in iron OD and when they would be used
* WBI if over 60mg/kg * Gastric lavage via ETT and witing 90 mins ingestion * surgical or endoscopic removal over 120mg/kg
30
what is the drug and dose for iron chellation?
Desferrioxamine IV. 15-40 mg/kg/hr
31
32
iron overdose, List two relevant findings and how it may alter management
RUZ consildation with no evidence of iron in GI tract no need for WBI - may need bronc
33
what bloods may you order in suspected iron OD
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
34
common agents for QT prolongation
The anti Antibiotics - cipro, clarithro Antidepressants - SSRI, TCA, lithium antipsychotics - haloperidol, chlorpromazine antihistamines - loratidine
35
Examination features of serotonergic toxidrome
36
main features What illicit drugs can cause this? Treatment?
widespread st elevation narrow complex tachy depression avr **Drugs** * sympathomimetic eg cocaine, ecstasy * LSD * volatile agents Treatment IV benzos calm environment GTN infusion ?thorombolytics
37
what underlying condition can predispose you to methaglobulinaemia
G6PD
38
what is the dose of activated charcoal
50g 1g/kg in paeds
39
what are the contraindications for activated charcoal
active resus aspiration risk charcoal wont bind eg metal benign agent sub toxic dose too long since ingestion
40
what are the features of significant carbamazepine overdose
anti cholinergic effects CNS - LOC, seizure, ataxia, nystagmus CVS - hypotension, tachy or brady arrthymia, prolonged PR, QRS, QT
41
With any drug related seizure, wht should be ruled out?
hypoglycaemia eclampsia infection hyponaetramia co-ingestion ICH
42
propanolol life threatening effects of OD and the management
* Coma - airway protection * seizures - benzos * brady/hypotension - atropine, adrenaline, noradrenaline * sodium channel blockade - bicarb * VF
43
OD low GCS ECG findings what drugs tend to do this?
broad QRS RAD prolonged QT TCA
44
list the abnormalities and reason why What is the most likely clinical scenario
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
45
is there a role for decontamination in liquid paracetamol? what is the threshold for liquid paracetamol and when should you measure level?
no - absorption is too quick 200mg/kg of liquid - 2 hours
46
what are the one pill killers for kids?
verpamil diltiazem sodium channel blocks eg TCA opiates gliclazide theophylline
47
what are the steps when someone gets an anaphylactoid rash with NAC
stop bronchodilator if wheezy anti histmiane pred 1mg/kg start at slower rate
48
what are the indications for activated charcoal in paracetamol OD
within 2 hours for immediate release within 4 hours for sustained release massive (over 30gm) within 24 hours
49
what is the criteria for cessation of NAC
if non toxic - repeat paracetmol below line and falling if toxic - NAC complete and ALT less than 50 and paracetamol less than 10
50
what are the criteria for transfer to liver unit post paracetamol OD
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
51
what is a terminal R wave in v3 suggetive of?
TCA overdose
52
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
53
risk assessment
large ingestion of lethal agent GCS already 14 alreasy showing biochemical signs
54
what are the decontamination methods for K OD Pro and con for each
WBI - good because quikcer then dialysing, hard becuase need intubation and staff to manage this dialysis - good because definitive but invasise
55
differentials for methaglobulinaemia with prilocane what is definitive test? treatment options
anaphylaxis seizure VT Test - ABG for saturation gap - pa02 v sats methyline blue high flow o2 HBOT vitamin C NAC
56
HAGMA with respiratory alkalosis WINTERS = Expected Co2 = 1.5 x HCO3 +8 +/-2
57
what blood gas features are most consistent with toxic alcohol ingestion?
high lactate high osmolar gap high anion gap
58
what are the important investigations with ?toxic alcohol ingestion and why
59
what are the treatments for toxic alcohol overdose
60
what are the clinical features of salicylate toxicity?
* initial hyperventilation * tinnitus * nausea * vimiting * dehydration * pyrexia * confusion * dehydration
61
for salicylate OD
62
what drugs can be used to manage serotonin syndrome
benzos serotonin agonists - olanzapine, chlorpromazine
63
drugs that cause serotonin syndrome
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
64
Low GCS interpret and list tox causes
HAGMA Causes Cyanide o Isoniazid, Iron o Alcohol (ethylene glycol, methanol, propylene glycol) o Salicylates o Valproate o Paraldehyde
65
what are the signs and symptoms of cyanide toxicity
66
treatment for cyanide toxicity
67
what paralytic is unsafe in hyperthermic patient?
sux
68
unresponsive after femoral nerve block with bupivicanine What do you do? what are specific antidotes?
stop injection begin CPR as per aLS support airway and oxygenate antidotes intralipid 20% 1-1.5ml/kg every 3 minutes then infusion
69
causes of tachycardia post intubation and historical feature
70
four important complications of GHB overdose
coma agitation fluctuation consciouness hypotension aspiration secondary injuries
71
what are the indications for intubation with GHB
* cant maintain away * hypoventilation * extreme agitaiton * resp failure * aspiraiton * concern for head injury
72
73
why may ETc02 be high after intubating?
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
74
key in benztropine OD
no sweating
75
76
features of meth intoxication
Agitation/Anxiety/ Hypervigilence Paranoia/Hallucinations Psychomotor agitation – restlessness, tremor Pressured speech Sweating, flushed skin Teeth Grinding, Jaw clenching Mydriasis Hypertension Tachycardia
77
what are the indications for haemodialysis in toxic alcohol ingestion
large ingestion with osmolar gap over 10 PH less than 7.3 renal failure clinical deterioration
78
79
dose dependant clinical features of olanzapine OD
80
Quetiapine: Lethal dose Effects treatment
* over 3 g * anticholinergic, plus coma and hypotension Histamine receptor blockade * benzos for agintation, intubation for coma, fluids and norad (not adrenaline) for hypotension NO ADREANLINE
81
What are the symptoms of cholinergic syndrome and what causes it? treatment
increased parasympathetic organophosphates, physostigmine, sarin benzos for seizures, atropine 0.02mg/kg pr pralidoxime and double dose 3-5 mins
82
Mental status, eyes, lungs, obs, bowel sounds, bladder and neuro for: Sympathomimetic/gaba withdrawal Cholinergic Anticholinergics Opiod withdrawal NMS serotonin syndrome
83
How does fomepizole or alcohol work in methanol poisoning
84
Symptoms toxic alcohol poisoning
85
SS v NMS
86
salicylate dangerous dose
over 150 - sx over 300 severe
87
decontamination of hydrofluric acid indications endoscopy
nothing to eat and drink - remove clothing and flush eyes with saline endoscopy - abdo pain or GI features eg haematemsis, vomiting
88
nac dose
200 mg/kg over 4 hours 100 mg/kg over the next 16 hours
89
100% hydroflouric acid - what level causes systemic investigations and signs of tox antidote
over 2.5% - hydrogen ions bind to calcium causing cellular damage - seizure possible **Ix** Ca/Mg/K - hypocal/Mg and high K ECG - prolonged QT interval **antidote - ** * calcium gluconate IV 10% - 60mmol * topical calcium gluconate 2.5% * s/c mix with normal saline * nebulised for inhalation
90
what electrolye abnormality is mdma linked to and why
Na - SIADH/polydipsia
91
toxic dose panadol over 48 hours?
anything over normal dose (4g/day)
92
when would you just start NAC
over 10g 200mg/kg

1. Fellowship Written - SAQ (30 decks)

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