Toxicology Flashcards
what must be considered when dealing with toxic pt?
dose (manifestations may be related to how much they took) route intentional/unintentional time elapsed (how long has it been since you took this?)
snorting
insluphation
toxidromes
toxic substance
AMS
altered mental status (frightened, agitated, delerium)
-overdose should always be in the differential when a pt presents with this
differential of AMS
AEIOUTIPS alcohol/acidosis electrolytes/epilepsy infection (sepsis, elderly) opiates/overdose uremia (kidney failure) trauma/toxicity/tumor insulin (hypoglycemic/hyperglycemic) psych stroke
steps to manage patient
ABC -airway (protect it proactively)
D-decontamination (remove garments)
E-easily correctable issues (hypoglycemia, hypoxia, hypotension, hypo/hyperthermia)
what is the most common OTC overdose?
acetaminophen
what organ does acetaminophen affect?
liver
encephalopothy
what is the max dose in people of acetaminophen?
4gms (adults)
90mg/kg (children)
toxicity is assoc with what dose of acetaminophen
150mg/kg
what is the first stage of acetaminophen overdose?
stage 1: asymptomatic, anorexia, nausea/vomiting, LFTs (liver enzymes) rise in the first 24 hours
what is the 2nd stage of acetaminophen overdose?
18-24 hrs post ingestion RUQ pain continued rise in LFTs and aPTT oliguria (urine output drops) tachycardia hypotension
what is the 3rd stage of acetaminophen overdose?
72-96 hrs post ingestion
continued abdominal pain
hepatic necrosis and encephalopathy (due to rising ammonia levels because liver can’t break down nitrogenous wastes of protein synthesis)
jaundice
GI bleeding
LFTs peak, ammonia and bilirubin continue to rise
what is the 4th stage of acetaminophen overdose?
4dys -2weeks
resolution of hepatic abnormalities of liver failure
LFTs come down
what lab studies will you order with acetaminophen overdose?
CBC
CMP
arterial blood gasses (ABG)
acetaminophen level (recheck every 4 hrs)
U/A
RUQ ultrasound (grossly enlarged gallbladder?)
CT of the head (with evidence of encephalopathy)
EKG (for baseline)
what are examples of salicylates?
aspirin
pepto-bismol
oil of wintergreen
what drug is taking the place of aspirin as a common overdose drug?
anti-depressants
what is the early presentation of aspirin OD?
early (1-2 hrs post ingestion)
- tinnitus
- vertigo
- Nausea/Vomiting/Diarrhea
- hyperpyrexia
- coma
what is the later presentation of aspirin OD?
hypernea blood gas abnormalities -respiratory alkalosis (CO2 is leaving the body) -metabolic acidosis -cerebral edema (AMS) (cleared in the liver and kidney)
what labs do you order for aspirin OD?
salicylate levels CBC CMP LFT ABG (blood gasses) UA (protein will go up, spill blood in the urine)
what are the normal/abnormal levels of salicylate?
110 mg/dL severe toxicity
what are exampels of opioids
codeine morphine hydrocodone oxycodone heroine
what is the presentation of opioid OD?
respiratory depression pinpoint pupils (lost light reaction-no dilation)
when are the peak effects of opioid with IVs?
10 min with IV route
when are the peak effects of opioid with insufflation?
10-15 min
when are the peak effects of opioid with IM administration? (intermuscular)
30-45 min
when are the peak effects of opioid with oral ingestion?
90 min
when are the peak effects of opioid with dermal application?
2-4 hours
what labs should you order with opioid OD?
CBC CMP ABG toxicity screen-often times qualitative (opioids, canabis, salycilates, acetaminophen) abdominal film (body packers)
what is the peak effect of cocaine via inhalation?
1-5 min
what is the peak effect of cocaine via IV?
3-5 min
what is the peak effect of cocaine via nasal?
15 min
what is the peak effect of cocaine via oral?
60 min
what is mild presentation of cocaine OD?
euphoria
agitation
tachycardia
hypertension
what is moderate presentation of cocaine OD?
stroke renal ischemia seizures ventricular dysrhythmias apnea cyanosis hyperthermia coma death
what are the physiologic affects of cocaine
vasoconstrictor
cardiotoxic
long term use = constrictive cardiomyopathy
what labs would you order with cocaine OD?
CBC CMP UA EKG (baseline) tox screen
what are examples of benzodiazepines
valium xanax ativan klonopin librium (older, not used as much) tranxene (older, not used as much) -extremely addictive, designed for short, acute,use
presentation of benzo OD?
coma with normal vital signs nystagmus (horizontal typically) hallucinations slurred speech ataxia (stumble, clumsy gait) AMS agitation Respiratory depression
what labs would you order with benzo OD?
CBC
ABG
tox screen (if suspect multiple ingestion)
no set test to identify benzos in blood or urine
what are examples of antidepressants?
tricyclics
- elavil
- pamelor
- tofranil
- vivactyl
presentation antidepressant OD?
CNS sedation confusion delirium hallucinations cardiac arrhythmias (widened QT interval-ventricular dysrythmias )
what labs would you order for antidepressant OD?
EKG tox screen (nothing else involved) TCA levels (qualitative only) salicylate levels acetaminophen levels
ethanol
ETOH
BAC of 0.01-0.1 presents with
euphoria
mild coordination deficits
attention and cognition
BAC of 0.1-0.2 presents with
coordination deficits and psychomotor skills, decreased attention, slurred speech, ataxia, impaired judgment and mood variability
BAC of 0.2-0.3 presents with
lack of coordination, incoherent thoughts, confusion and nausea and vomiting
BAC of >0.3 presents with
stupor and loss of consciousness
coma
respiratory depression and death
what is a common complication of vomiting while drunk?
aspiration
things to consider with ETOH
BAC may not correlate with S & S
watch out for respiratory depression
labs for ETOH
ETOH level
ABGs
tox screen (if something else is going on)
why is carbon monoxide dangerous?
it has a greater affinity for hemoglobin compared to oxygen (300 times greater)
presentation of acute CO poisoning
headache (most common) malaise nausea dizziness can be misdiagnosed as ETOH intoxication chest pain (AMI)
presentation of long term CO poisoning
cognitive deficits personality changes movement disorders (ataxia that doesn't resolve)and focal neurological deficits
what social group has higher levels of CO?
smokers
labs for CO poisoning?
Pulse ox is NOT reliable, cannot distinguish between O2 and carboxyhemaglobin
ABGs (smokers may have 10-15% baseline)
