Toxicology

Question 1

most common cause of acute liver failure in US

Answer 1

acetaminophen toxicity

Question 2

Phase 1 aceteminophen OD

Answer 2

30 minutes – 24 hours after

Anorexia, fatigue, nausea vomiting, diarrhea, diaphoresis

Question 3

Phase 2 aceteminophen OD

Answer 3

18-72 hours after
RUQ abdominal pain, nausea, vomiting
Tachycardia, hypotension, oliguria

Question 4

Phase 3 acteteminophen OD

Answer 4

72-96 hours after
GI symptoms persist, tender liver
Hepatic dysfunction / necrosis → jaundice, coagulopathy, encephalopathy
Acute renal failure and death

Question 5

Toxic serum acetaminophen level

Answer 5

> 250 mcg/mL

Question 6

Labs other than serum acetaminophen that would be ordered for suspected OD

Answer 6

CMP- AST/ALT will be high – 1000+ when 40 is normal.
Bilirubin high
Alkphos up
PT/PTT times will be longer
If end result is renal failure, will see creatinine is going to be elevated
Glucose will be down bc liver creates new glucose, and that is impaired
Can also develop pancreatitis get a amlyase and lipase

Question 7

Salicylate drug class

Answer 7

NSAIDs, Aspirin is most common.
Pepto-Bismol ® (bismuth salicylate)
Diurex ® (magnesium subsalicylate)
Oil of wintergreen (used in Chinese herbal medicine)= 1 tsp = 7 grams of salicylate = 22 adults aspirins → 4ml can be fatal in a child

Question 8

Reyes syndrome

Answer 8

can occur with aspirin use with a viral illness. Manifests with vomiting, lethargy, irritability, delirium, seizures, coma.

Question 9

Salicylate OD sx

Answer 9

tinnitus, vertigo, N/V/D, altered mental status, pulmonary edema, arrhythmia, liver damage. Measure serum salicylate levels every 2 hours.

Question 10

Severe repercussions of alcohol use

Answer 10

multiple metabolic/electrolyte disturbances, hypotension, stupor, coma and death

Question 11

BAC

Answer 11

Percentage of alcohol or mass units of alcohol in the blood
Example=
BAC 0.1%= 0.1 grams of alcohol per every deciliter of blood

Question 12

Body clears alcohol at a rate of

Answer 12

of 0.015 of BAC per hour

Question 13

Methanoly and ethylene glycol commonly found in

Answer 13

Antifreeze
Windshield wiper solutions
Solvents
Cleaners
Fuels
Miscellaneous industrial products

Question 14

methanol intoxication sx

Answer 14

Vision blurring
Central scotomata (darkening of a visual field)
Blindness

Question 15

Ethylene glycol intoxication sx

Answer 15

Flank pain
Hematuria
Oliguria

Question 16

If you suspect Ethylene glycol intoxication, you should order blood serum levels

Answer 16

FALSE. it can take 2 days to get results. History is more important.

Question 17

Isopropyl alchohol

Answer 17

most commonly found in rubbing alcohol. Ingested to cause intoxication or self harm. It is more potent than alcohol when comparing ounce per ounce. Its rarely fatal though

Question 18

if you suspect ethylene glycol intoxication, you should order blood serum levels

Answer 18

only to confirm the diagnosis. Pt hx is important.

Question 19

Lead

Answer 19

Watch out for lead poisoning in urban, low income children. Paint from houses older than 1980’s, Dirt from surrounding areas, gasoline additive pre-1970s and lead pipe water.

Question 20

Lead poisoning sx

Answer 20

decline in Mental status, muscle weakness, headaches, memory loss, mood disorder, premature birth. Children can have behavior issues, ADHD, developmental delays. Hearing loss, renal, GI and neuro issues.

Question 21

excessive mercury exposure

Answer 21

fatal pneumonitis, intention tremor, gum inflammation, excessive salivation, psychiatric symptoms. Children may develop body rashes that lead to desquamation, irritability, photophobia, fever, sweating, fever (“pink disease”).
Excessive mercury can cause renal toxicity.

Question 22

Arsenic found in

Answer 22

volcanic eruptions, pesticides, mining, pressure treated wood, some apple and grape juice.

Question 23

Arsenic poisoning sx

Answer 23

N/V/ abdominal pain, abnormal EKG, cardiac issues–> death, Skin lesions- hyper pigmentation is early and common sign.

Question 24

Drug of abuse screen, typical

Answer 24

Amphetamines, cocaine, THC, opiods, PCP. All tested rapidly.

Question 25

Zinc sulfate

Answer 25

can alter result of a urine drug test

Question 26

How do you test for urine “spiking”?

Answer 26

Check for the metabolite of that medication. Can also test urine specific gravity, temperature, pH, and creatinine

Question 27

What can make an amphetamine drug test positive?

Answer 27

OTC and herbal products, Nasal decongestants, Ephedrine, Bupropian.

Question 28

What can make a cocaine test positive?

Answer 28

Coca tea/leaves (illegal in US). Cocaine can also be used in topical anesthesia for ENT procedures. False positives are not common through.

Question 29

What can make a THC test positive?

Answer 29

Test for the metabolite of Delta-9 THC, this is the most specific. Can get a false positive with ingestion of hemp products.

Question 30

Typical opiod test

Answer 30

Codeine, Heroin, Morphine, Hydromorphone

Question 31

What can make a PCP test positive?

Answer 31

Benadryl, Nyquil, DM drugs, Tramadol.

Question 32

What is the issue with benzodiazepines?

Answer 32

They are rx and used for sleep and anxiety, but have a high potential for abuse. They are sold on the street. A benzo drug test cannot detect sleep medications.

Question 33

Digoxin

Answer 33

An antiarthytmic drug that has a very narrow therapeutic window. You need to check levels constantly to avoid toxicity, especially if your pt has renal impairment or is older.

Question 34

When will you test digoxin levels?

Answer 34

7 days after you start it. Most accurate when you do it 6-8 hours after dose. Repeat levels every 3-6 months.

Question 35

Anticonvulsants that require monitoring

Answer 35

Carbamazepine, Divalproex, sodium, Valproate sodium, Phenobarbital, Phenytoin, Primidone

Question 36

Lithium

Answer 36

used for bipolar disorder as an anti-manic. Has a narrow therapeutic index and is worse in the elderly. Need to check levels 5-7 days after you start it and then every 6-12 months.

Question 37

Lithium toxicity sx

Answer 37

N/V/D, bradycardia, Ataxia, confusion, tremors, jerks

Question 38

When do you check Vancomyacin trough levels?

Answer 38

just before the 4th dose. Check more frequently in its with decreased renal function.

Question 39

Theophylline

Answer 39

Used for reactive airway disease. Measure theophulline levels to avoid toxicity and to measure therapeutic response.

Question 40

Carboxyhemoglobin

Answer 40

CO poisoning from smoke inhalation and improper venting. Binds to Heme better than O2 and leads to O2 offloading. Screen based off of history. Level done via ABG.

Question 41

Methemoglibin

Answer 41

When Fe is +3 instead of +2. When it is like this, O2 cannot bind. This can be congenital, most cases are mild enough that they do not require tx.

Question 42

acquired methemoglobinemia

Answer 42

Organic and inorganic nitrites from prepackaged foods.
Certain medications- dapsone, topical anesthetics (lidocaine, prilocaine, benzocaine).
Well water.
Chlorates found in matches, explosives and fungicides

Question 43

Methemoglobinemia clinical presentation

Answer 43

can vary from slight blue discoloration of the skin to headache, chest pain, cardiac issues, seizures, and even death.

Question 44

The blue fugues of kentucky

Answer 44

a family that had congenital methemoglobin- had blue skin. Some still exist. dun. dun. dunnnnn.