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ER Part 2 > TOXICOLOGY > Flashcards

TOXICOLOGY Flashcards

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1
Q

What is harder to treat – one time single large dose of Tylenol? Or: I took half a bottle today, yesterday, and the day after?

A

It’s worse if it’s over a time period

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2
Q

What should we remember about drugs with a narrow therapeutic windows?

A

Can become toxic with normal regimen

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3
Q

What are some key things we must ask about toxicology?

A

TIMING of ingestion if key

Talk to EVERYONE (you have to piece it together)

Ask about ALL OTC meds

Count pills

Remember patients may not appear toxic… INITIALLY

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4
Q

What entity is your friend/expectation with toxicology and you must consult them every time?

A

Poison control!

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5
Q

What blood test is most likely to change first with poisoning?

A

INR (will elongate out) then LFT’s

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6
Q

What 3 EKG changes are you looking for with poisonings?

A

High grade blocks, prolonged OT, terminal R wave (lead AVR), and wide QRS

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7
Q

What are the toxidromes?

A

pneumonic that help with syndromes

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8
Q

Why should we have a high suspicion for chronic OD in the elderly?

A

Polypharmacy; or docs not knowing what else they are taking

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9
Q

What does MUDPILES stand for?

A 
Methanol, 
Uremia, 
DKA, 
Propylene glycol, 
Infection/isonized, 
Lactic acidosis, 
Ethylene glycol/ethanol, and 
Salicylates (aspirin)
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10
Q

What is MUDPILES used for?

A

The elevated anion gap DDx list! Often the bicarb stinks

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11
Q

How do you calculate an anion gap?

A

Sodium, bicarb, and chloride (all in a Chem 8)

Na – (Bicarb + Cl)

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12
Q

What’s a normal Anion Gap?

A

less than 12

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13
Q

If a patient presents with delirium, hallucinations, and anxiety are associated with what toxicology?

A

Chronic Aspirin

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14
Q

If a patient presents with hyperventilation (Kussmal), pulmonary edema, tinnitus – what overdose would this be associated with?

A

Aspirin

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15
Q

What do you have Kussmal breathing (bit deep fast respirations)?

A

They’re trying to correct their metabolic acidosis

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16
Q

What is a UDPRO?

A

Urine drug screen – it’s a yes or no test

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17
Q

Can you order an aspirin level?

A

Yes, serum, and it’s quantitative

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18
Q

At what point does aspirin cause serious toxicity?

A

300-500mg/kg

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19
Q

How often are you checking salicylate levels?

A

Repeat every 2 hours (for 6 hours)– to see when it peaks or declines

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20
Q

What other workup do you do for toxicology?

A

Chemistries, creatinine, calcium, magnesium

ABG

Monitor urine pH

Coag & liver studies

EKG & CXR

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21
Q

What do we need to keep their urine levels at?

A

pH 7.5-8 (via bicarb)

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22
Q

Should you see EKG changes with an aspirin overdose?

A

No

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23
Q

Why would we do a chest xr for aspirin OD?

A

To see if there’s a big clump of pills in their stomach

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24
Q

Be careful with serum levels less than 6 hours post ingestion, why?

A

Because they won’t be absorbing anymore after 6 hours

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25
Q

What blood test will change first with aspirin ingestion?

A

LFT’s

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26
Q

What’s the best treatment for aspirin?

A

BICARB (alkalinize the urine)

Dialysis is the TOC (enhanced elimination, acid-base and electrolyte correction)

Gastric lavage (60 mins post ingestion)

If you give charcoal (within 30 mins) → there’s a risk of aspiration & green-apple poos

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27
Q

What are the take home points for aspirin OD?

A

Consider in the acute altered patient

Look for acidosis

Alkalize urine

Dialysis TOC

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28
Q

What’s the max daily dose of Tylenol for an adult?

A

4 grams!!

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29
Q

Why do children do better with Tylenol?

A

They have more glutathylenol (they can metabolize it better)

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30
Q

What other common co-ingestion significantly worsens Tylenol OD? Why?

A

Alcohol

It uses the same enzyme to metabolize Tylenol & alcohol!!!

31
Q

What’s the most common cause of acute liver failure in the US?

A

Tylenol

32
Q

What are the 4 phases of Tylenol od?

A

1 = Asymptomatic

2 = RUQ pain (18-72 hours)

3 = jaundiced, coagulopathy, fatality (72-96) → AKA toxicity is DELAYED

33
Q

What toasts your liver after glutathione is gone?

A

NAPQl

34
Q

What’s the first sign of Tylenol OD

A

LFt’s

35
Q

How often do we draw labs for Tylenol od, what do we use with it?

A

initial + every 4 hours

Rumack-Matthew nomogram (4 hours out)

36
Q

When does the Rumack fail you?

A

When there is a multiple ingestion over multiple days!

37
Q

What other labs should you test for Tylenol od?

A

AST/ALT; coag, and glucose

BUN/Cr (to r/o renal failure)

Lactate level (mortality)

ABG (acidosis → shouldn’t be present in a Tylenol od)

Type & Crossmatch

38
Q

How do you treat a tylenol od?

A

Iv, oxygen, cardiac monitor

NAC (N-acetylcystine) within 8 hours or anytime if pregnant

Consult poison control!

Charcoal within 30 mins

39
Q

At what point do you need a transplant (to the make the list)?

A

pH 100; serum creatinine >3.4

40
Q

So, what are the take home points with Tylenol od?

A

use rumack nomogram

Get help if multiple/chronic ingestion

NAC = TOC

Will get sick DAY later

41
Q

What types of meds often have a narrow therapeutic window, and will often become toxic without intentional overdose?

A

Psych meds = lithium & amitriptyline

42
Q

Agitation, confusion, tremor or rigidity, sweating, hyper-reflexia, anxiety, and ataxia are symptoms associated with what?

A

Serotonin syndrome (sxs remembered with anticholinergic toxidrome)

43
Q

What labs should you do for serotonin syndrome?

A

Look for rhabdo (CK)

44
Q

How do you treat serotonin syndrome?

A

Benzos, BP control, and cooling

45
Q

What’s the biggest complication with opiates?

A

Respiratory!!!

46
Q

What if you see arrhythmias with opiate od?

A

They would have to have been down a LONG time (there’s significant neuro damage)

*You don’t see heart problems with opiate od

47
Q

How do we reverse opiates?

A

narcan (naloxone)

48
Q

What are the extended release opiates?

A

Dilaudid & Methadone

49
Q

What’s critical about narcan?

A

IT’s half life is shorter than the opiate half life → Keep them in front of you!!! (otherwise they go into respiratory distress)

50
Q

What is the time to peak effect for opiates?

A

IV = 10 min

IM = 30

Oral = 90

Transdermal = 2-4 hours (minutes if it touches mucous membranes – they lick it. They will die if ingested)

51
Q

What type of labs should we do for opiate od?

A

ABC’s, tox screen (but not that helpful), FSBS (finger stick blood sugar), EKG, ABG, CXR

52
Q

How does a person wake up after narcan is administered?

A

ANGRY

53
Q

If you’ve given narcan and the person is still altered – what do you need to think?

A

Other ingestion

Methadone will need multiple narcan doses

54
Q

What are the rapidly fatal drugs?

A

TCA’s, ethylene glycol, Verapamil

55
Q

What’s the most common tricyclic antidepressant?

A

Amitryptyline

56
Q

What is a classic diagnostic finding of a tricyclic-antidepressants?

A

EKG = Wide QRS and terminal R wave in aVR

57
Q

What toxidrome is used for TCA OD?

A

SALT

Shock, AMS, wide (long) QRS, terminal R wave in aVR

It’s bad if they’re in shock, tachy, AMS

58
Q

What is a toxic dose of a TCA, how long dose it take to absorb?

A

Absorbs in 1 hour

Toxic dose = 10-20mg

59
Q

So, how do we treat TCA OD?

A

Bicarb!!

Serial EKG’s

Seizure precautions

60
Q

What is ethylene glycol?

A

Antifreeze

61
Q

How do you OD on ethylene glycol?

A

Drink it because it tastes sweet

62
Q

What’s the metabolism of ethylene glycol?

A

EG → Alcohol dehydrogenase → glycolic acid (cause of severe acidosis)

63
Q

If you see kussmal breathing, tachy, AMS (or obtunded), and no other gross abnormalities – is what diagnosis?

A

Ethylene glycol OD

64
Q

What is the workup for ethylene glycol od?

A

ABG, ETOH levels, FSBS

65
Q

You order an AG, chem 8, and a serum osmolarity – what do you do next?

A

Calculated osmolarity

SERUM & CALCULATED OSMOL SHOULD BE THE SAME

66
Q

How do you calculate osmolarity?

A

2(Na) + BUN level/3 + glucose/18

67
Q

If your serum osmol & calculated osmols don’t match what should you do?

A

Plug in the conversion factors → if they now match, you have made your diagnosis

68
Q

So how do you treat ethylene glycol?

A

Fluids, bicarb, FOMEPIZOLE = TOC (expensive, so you give them alcohol or dialysis)

69
Q

So dialysis is for what?

A

EG & Aspirin

70
Q

What will verapamil cause?

A

Vasodilation + bradycardia/hypotensive! B/C they are taking a CCB to control their BP!

71
Q

How much verapamil to get an od?

A

> 1gram

72
Q

What is the workup for verapamil?

A

AG, tox screen, EKG for high grade blocks!

73
Q

How do you treat a verapamil od?

A

Pacing, CaCL = TOC (reversal agent), also pressor or atropine

74
Q

SO what are the take home points for verapamil od?

A

Look for bradycardia with severe hypotension

Extended release formulations are the WORST

EKG looking for high grade blocks

Pressor support, 10% CaCL

ER Part 2 (7 decks)

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