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Toxicology Flashcards

1
Q

Initial Evaluation for a Toxicology Patient

A 
ABC's
ABGs as soon as practical
Obtain IV access
Treat coma promptly: glucose, naloxone, thiamine
Maintain circulation
Treat seizures
Cardiac monitoring and pulse oximetry
History
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2
Q

Train of Overdose Effects

A

CNS depression
Myosis
Respiratory depression

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3
Q

Medications to Treat Seizures in Toxicology Patients

A

Diazepam

Phenobarbital

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4
Q

Options for Decontamination of Ingested Toxins

A

Emesis
Gastric lavage
Activated charcoal
Whole bowel irrigation

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5
Q

Emesis as a Decontamination Option

A

Requires gag reflex
Limited efficacy if 1+ hour since ingestion
Ipecac + water

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6
Q

Contraindications to Inducing Emesis

A

Caustics
Low-viscosity hydrocarbons: gasoline, kerosene
Rapid-acting convulsants: meth, cocaine, cyclic antidepressants

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7
Q

Indications for Gastric Lavage

A

Serious ingestions when emesis has failed
Patients are lethargic or uncooperative
Gag-reflex markedly depressed
Patients have ingested rapid-acting convulsants

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8
Q

Methodology of Gastric Lavage

A

Large bore NG tube
Tap water or saline at body temp in 250 mL increments
Continue until fluid returns clear and free of pill fragments

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9
Q

What poisons does activated charcoal not adsorb?

A

P: potassium
A: alcohol
I: iron
L: lithium

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10
Q

What are some cathartic actions?

A

Speeds up GI transit time
Screws up electrolytes
Lots more vomiting
Severe abdominal cramp

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11
Q

When is a whole bowel irrigation useful?

A

Sustained release and enteric coated tablets

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12
Q

Initial Laboratory Studies in a Toxicology Patient

A 
ABGs
Chem 7
ECG: wide QRS or prolonged QT
CXR: pulmonary edema
Flat plate abdomen??
Urine for toxicology screen
Draw and hold serum toxicology screens
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13
Q

What does management of the patient require in toxicology patients?

A

Understanding of absorption, distribution, elimination

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14
Q

Define First-Order Kinetics

A

Fixed PERCENTAGE of the toxin is removed per unit of time

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15
Q

Define Zero-Order Kinetics

A

Fixed AMOUNT of toxin is removed per unit of time

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16
Q

Define Drug Clearance

A

Volume of plasma that can be cleared of toxin per unit time

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17
Q

When is hemodialysis used in patients who have overdosed?

A

When toxin is relatively water-soluble and not highly protein bound

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18
Q

Indications for Hemodialysis in Overdose Patients

A

M: methanol
E: ethylene glycol
L: lithium
S: salicylate

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19
Q

Advantage of Hemoperfusion over Hemodialysis

A

Drug/toxin in direct contact with adsorbent material

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20
Q

What is hemoperfusion commonly associated with?

A

Thrombocytopenia

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21
Q

What does hemoperfusion NOT do?

A

Correct electrolyte imbalances

Adjust pH

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22
Q

When is hemoperfusion useful?

A 
TRI: TCAs
P: paraquat
E: ethchlorvynol
P: phenobarbital
T: theophylline
D: digitoxin
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23
Q

Antidote for Acetaminophen

A

Acetylcysteine

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24
Q

MOA of Acetylcysteine

A

Bind to NAPQI so it can’t accumulate

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25
Antidote for Anticholinergics
Physostigmine
26
What other uses are there for physostigmine?
Myasthenia graves | Short term memory
27
Antidote for Benzodiazepines
Flumazenil: if infusion too rapid, patient will seize
28
Antidote for Cyanide
Na nitrite | Na thiosulfate
29
Antidote for Methanol/Polyethylene Glycol (anti-freeze)
Ethanol
30
Antidote for Narcotics
Naloxone (Narcan)
31
Intoxicant for Osmolar Gap Greater than 30
An alcohol
32
Acetaminophen Toxicity
Delayed hepatotoxicity (24-72 hours)
33
How soon should one get an acetaminophen level and begin treatment?
Within the first 16 hours
34
Treatment of Acetaminophen Overdose
Decontaminate Give activated charcoal Estimate severity (acetaminophen level) Acetylcysteine therapy
35
MOA of Acetylcysteine
``` Substitutes glutathione Binds NAPQI (metabolite) ```
36
When should acetylcysteine be administered?
Early MUST: 12-16 hours PREFERABLE: 8-10 hours
37
Symptoms of Acetaminophen Overdose Within 4 Hours
Anorexia N/V Sweating
38
Symptoms of Acetaminophen Overdose 3+ Days Out
Encephalopathy Marked elevation in LFTs Renal failure
39
Symptoms of Acetaminophen Overdose Greater than 1 Week Out
Begin to return to normal
40
Cocaine and Amphetamine Overdose Symptoms
``` Vasoconstriction HTN Bradycardia Ventricular arrhythmias Seizure and hyperthermia may produce rhabdomyolysis and myoglobinuria ```
41
Significant Cocaine Overdose Symptoms
``` Euphoria Excitement Restlessness Toxic psychosis Seizures HTN Tachycardia Hyperthermia Possible MI ```
42
What drug does cocaine have a synergistic effect with?
Alcohol
43
Treatment of Cocaine or Amphetamine Overdose
``` GI decontamination Diazepam Nitroprusside Monitor temperature and EKG +/- head CT ```
44
Why administer diazepam in cocaine or amphetamine overdose?
Severe agitation or psychosis | Treat seizures
45
Why administer nitroprusside in cocaine or amphetamine overdose?
DBP >120 | HTN encephalopathy
46
MOA of Anticholinergics
Block cholinergic receptors both centrally and peripherally
47
Symptoms of Significant Anticholinergic Poisoning
``` Delirium Blurred vision Mydriasis Hallucinations Coma Dry mucous membranes Inhibition of sweating Hyperthermia Tachycardia ```
48
When would you administer physostigmine in a anticholinergic overdose?
Peripheral and moderate central symptoms
49
Treatment of Anticholinergic Overdose
Supportive care GI decontamination Physostigmine (severe symptoms)
50
Conditions with Physostigmine Administration
Atropine available: bradycardia | Must be on cardiac monitor
51
When must you never physostigmine?
TCA overdose Asthma Mechanical bowel Bladder obstruction
52
Main Anticoagulant
Warfarin (Coumadin)
53
MOA of Warfarin (Coumadin)
Block vitamin K dependent clotting factors (II, VII, IX, X)
54
When are peak effects seen with warfarin (Coumadin) overdose?
1-2 days
55
Presentation of Excessive Anticoagulation
``` Ecchymosis Hematuria Uterine bleeding Melena Epistaxis Gingival bleeding Hemoptysis Hematemesis ```
56
Treatment of Excessive Anticoagulation
``` Supportive therapy GI decontamination Baseline PT & repeat in 24-48 hours Vitamin K IV FFP in bleeding emergency ```
57
Examples of Items that Include Arsenic
Insecticides Rodenticides Wood preservatives
58
Methods of Arsenic Absorption
Respiratory GI Binds with tissue proteins
59
2 Clinical Syndromes of Arsenic Poisoning
Arsenic salt ingestion | Arsine gas inhalation
60
Symptoms of Acute Arsenic Ingestion
``` Crampy abdominal pain Vomiting Profuse watery diarrhea Burning mucosa Conjunctivitis Tremor Seizures Garlic odor Periorbital edema (1-2 days) ```
61
Symptoms of Chronic Arsenic Ingestion
``` Peripheral and sensory neuropathy Malaise Anorexia Alopecia Anemia Stomatitis ```
62
Arsine Gas Inhalation Effects
Highly toxic Rapid intravascular hemolysis Renal failure
63
Treatment of Acute Arsenic Ingestion Poisoning
GI decontamination GI lavage Charcoal Dimercaperaol (BAL) x 5 days
64
Treatment of Chronic Arsenic Ingestion Poisoning
Penicillamine QID
65
Treatment of Arsine Gas Inhalation
Transfusion | Adequate hydration
66
Diagnosing Mild CO Poisoning
COHgb level | ECG
67
Diagnosing Moderate to Severe CO Poisoning
``` COHgb level ABG Chem 7 Serum lactate CBC EKG Serum CK-MB and troponin Urine myoglobin CXR ```
68
Treatment of CO Poisoning
100% FiO2 for 4 hours
69
Symptoms of CO Poisoning
``` Fatigue Malaise Flu-like N/V Confusion Loss of memory Emotional lability Dizziness Paresthesias Weakness Lethargy Somnolence Stroke Coma Seizures Respiratory arrest Chest pain Myocardial ischemia Palpitations Dysrhythmias Poor cap refill Hypotension Cardiac arrest ```
70
Indications for Hyperbaric Oxygen Therapy Referral
``` AMS or abnormal near exam Hx of LOC or near-syncope Hx of seizure Coma Hx of hypotension with exposure Myocardial ischemia Hx of prolonged exposure Pregnant with COHgb levels >15% Persistent acidosis (relative) Concurrent thermal or chemical burns (relative) ```
71
MOA of Digitalis
Enhance cardiac contractility Slow AV conduction Enhance automaticity
72
Symptoms of Digitalis Poisoning
``` Anorexia N/V Diarrhea Abdominal pain Blurred vision Color vision disturbance ```
73
Signs of Digitalis Poisoning
``` 3rd degree AV block Bradycardia Ventricular ectopy Paroxysmal atrial tachycardia with AV block HYPERkalemia ```
74
Treatment of Digitalis Poisoning
Glucose + insulin therapy Bradycardia: atropine, pacing Ventricular ectopy: lidocaine Digibind (severe)
75
Symptoms of Excessive Ethanol
Ataxia Dysarthria Depressed sensorium Nystagmus
76
Treatment of Excessive Ethanol
Supportive Watch blood glucose levels Thiamine
77
Symptoms of Amatoxin Associated Mushrooms
Severe gastroenteritis | Delayed hepatic and renal failure (48-72 hours)
78
Treatment of Amatoxin Associated Mushrooms
Supportive Admit to hospital Baseline renal and hepatic functions
79
Symptoms of Muscarine Associated Mushrooms
Salivation Miosis Bradycardia Diarrhea
80
Onset of Amatoxin Symptoms
6-24 hours
81
Onset of Muscarine Symptoms
30 minutes-1 hour
82
Treatment of Muscarine Associated Mushrooms
Supportive | Atropine (severe)
83
Symptoms of Psilocybin Associated Mushrooms
Hallucination
84
Onset of Psilocybin Symptoms
15-30 minutes
85
Treatment of Psilocybin Associated Mushrooms
Supportive
86
Symptoms of Isotonic Acid and Muscimol Associated Mushrooms
Mydriasis Tachycardia Hyperpyrexia Delirium
87
Treatment of Isotonic Acid and Muscimol Symptoms
Supportive | Physostigmine (severe)
88
Onset of Isotonic Acid and Muscimol Symptoms
30 minutes to 2 hours
89
Symptoms of Monomethylhydrazine Associated Mushrooms
Severe gastroenteritis Hemolysis Hepatic and renal failure
90
Onset of Monomethylhydrazine Symptoms
6-12 hours
91
Treatment of Monomethylhydrazine Associated Mushrooms
Supportive | IV pyridoxine
92
SE of Opiates
``` Sedation Hypotension Bradycardia Hypothermia Respiratory depression ```
93
Diagnosis of Opiates
Toxic levels in urine | Reversal of symptoms with naloxone (Narcan)
94
Treatment of Opiate Overdose
Naloxone (Narcan) | Admit to hospital
95
Examples of Organophosphates
``` Crop sprays Home insecticides Bug "bombs" Flea collars Chemical warfare agents Terrorist agents ```
96
MOA of Organophosphates
Inhibit cholinesterase causing accumulation of acetylcholine
97
Symptoms of Organophosphate Poisoning
``` Miosis Excessive salivation Bronchospasms Hyperactive bowel sounds Lethargy Muscle fasiculation Seizures Bradycardia or tachycardia ```
98
Pneumonic and Meaning for Organophosphate Poisoning Symptoms
``` D: diarrhea U: urination M: miosis B: bronchospasms E: excitation L: lacrimation S: salivation ```
99
Treatment of Organophosphate Poisoning
``` Decontamination Airway management IV Atropine Pralidoxime (2-PAM) Admit to hospital Avoid future exposures ```
100
Methods of Bringing Phencyclidine (PCP) into the Body
Smoked Snorted Ingestion Injection
101
What type of agent is Phencyclidine (PCP)?
Sympathomimetic Hallucinogenic Dissociative agent
102
Symptoms of Phencyclidine (PCP)
``` Vertical and horizontal nystagmus HTN Tachycardia Hyperthermia Marked muscle rigidity Dystonias Seizures ```
103
Goals of Treatment
Limit seizures | Limit violence
104
Treatment of Phencyclidine (PCP) Overdose
Diazepam Haloperidol Monitor and prevent rhabdomyolysis
105
What is the worst overdose to care for with the absolute worst outcomes regardless of skill?
TCAs
106
Symptoms of TCA Overdose
``` Mydriasis Dry mouth Tachycardia Agitation Hallucinations Coma Refractory seizures Widening of QRS Prolonged QT and PR intervals Possible AV block Torsades possible Hypotension ```
107
3-Cs of TCA Toxicity
Cardiac abnormalities Convulsions Coma
108
Treatment of TCA Toxicity
``` Gastric lavage Instill charcoal Continuous cardiac monitoring Diazepam (seizures) Lidocaine (ventricular arrhythmias, hypotension) ```

Emergency Medicine (17 decks)

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