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Emergency Medicine > Toxicology > Flashcards

Toxicology Flashcards

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1
Q

Ipecac? Gastric lavage?

A

V. rarely used. Gastric lavage - only with ET tube (AMS, uncooperative); prevent aspiration, laryngospasm.

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2
Q

Activated charcoal?

A

Yes, immediately. Do not use with hydrocarbons, acids/alkalis. Does not tend to work well for lithium, K+, iron, some metals, alcohols. Risk - aspiration pneumonitis. Do not use cathartics.

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3
Q

Whole bowel irrigation (GoLYTLETY, Colyte)?

A 
Use in:
-lithium, heavy metals, iron
-multiple packets of drugs
-sustained release tablets
Must be able to sit on toilet.
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4
Q

“GI Dialysis”

A

Multiple doses of activated charcoal. Effective for theophylline, pentobarbital, carbamazepine, quinine.

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5
Q

Hemodialysis?

A

ASA, lithium, methanol, ethylene glycol.

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6
Q

Charcoal Hemoperfusion?

A

Theophylline, pentobarbital; rarely available.

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7
Q

Labs in Intoxication Pt

A

Bedside glucose, (+) naloxone, urine/blood toxicology; EKG, acetaminophen level (+NAS w/in 8 hr), CXR, KUB, LFTs, UA, acid-base status, serum Osms.

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8
Q

Toxidrome - Anticholinergic

S/S, Common Causes

A

Agitated delirium, visual hallucinations, mumbling speech, tachycardia, DRY FLUSHED SKIN, DILATED PUPILS, myoclonus, temp up, URINARY RETENTION, decreased bowel sounds –> seizures, dysrhythmias.

!!! Antihistamines, antiparkinsonism medication, atropine, scopolamine, amatadine, antipsychotics, antidepressants, mydriatics, skeletal muscle relaxants, many plants (jimsyn weed).

** “Blind as a bat, mad as a hatter, red as a beet, hot as Hades (or hot as a hare), dry as a bone, the bowel and bladder lose their tone, and the heart runs alone.” **

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9
Q

Toxidrome - Sympathomimetic

S/S, Common Causes

A

Delusions, agitation, paranoia, tachycardia, HTN, hyperpyrexia, diaphoresis, piloerection, mydriasis, hyperreflexia –> seizures, dysrhythmias.

Cocaine, amphetamines, methamphetamines (MDA/MDMA, MDEA), OTC decongestants (ephedrine).

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10
Q

Toxidrome - Opiate/Sedative

S/S, Common Causes

A

Coma, resp depression, mitosis, hypoTN, bradycardia, hypothermia, acute lung injury, decreased bowel sounds, hyporeflexia, needle marks.

Narcotics, barbs, BZDs.

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11
Q

Toxidrome - Cholinergic

S/S, Common Causes

A

SLUDGE MM: Salivation, lacrimation, urination, diarrhea, GI distress, emesis, mitosis, muscle spasm.

DUMBBELSS: Diarrhea, urination, miosis, bronchospasm, bradycardia, emesis, lacrimation, salivation, sweating.

Organophosphate and carbamate insecticides, physostigmine, edrophonium, some mushrooms.

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12
Q

Unconscious OD Pt? Give…

A

dextrose + naloxone (2 mg in acute OD; multiple 0.2 mg doses in chronic opioid use to prevent withdrawal)

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13
Q

Anticholinergic Toxidrome? Give…

A

Physostigmine, 1-2 mg IV slowly. NEVER give in TCA OD (i.e., EKG w/ QRS widening, large R wave in aVR).

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14
Q

Digitalis Poisoning? Give…

A

Digoxin immune Fab (Digiband, Digitab), up to 10 vials, must wait 20 min for response.

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15
Q

Cholinergic Toxidrome? Give…

A

Atropine (dry pulmonary secretions) + pralidoxime (reverse skeletal m. toxicity).

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16
Q

BZD OD? Give…

A

Usually nothing…if acute BZD OD resulting in significant toxicity, give flumazenil. May cause BZD withdrawal, seizures. Give 0,2 mg…30 secs…0.3 mg…30 secs…0.5 mg - repeat up to total 3 mg.

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17
Q

Methanol/ethylene glycol poisoning? Give…

A

Ethanol and fomepizole - alcohol dehydrogenase blocking agents; prevent metabolism to toxic metabolites.

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18
Q

Acetaminophen OD? Give…

A

N-acetylcysteine, best if w/in 8 hrs. PO 140 mg/kg loading dose + 70 mg/kg q4hrs). IV 150 mg/kg in 200 ml D5W over 15 min loading dose + 50 mg/kg in 500 ml D5W over 4 hrs + 100 mg/kg in 1 L D5W over 16 hr.

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19
Q

EtOH Withdrawal? Give…

A

BZD (diazepam, lorazepam) +/– haloperidol for hallucinations.

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20
Q

Acute AWDs? Chronic AWDs?

AWDs = alcohol withdrawal seizure

A

Acute – Airway, 50% dextrose, BZD (IV + 2-days post seizure).
Chronic – (i.e., epileptogenic focus) phenytoin, etc.
PREVENT WITH BZDs!

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21
Q

Complications of chronic alcoholism or binge drinking…

A

EtOH-induced hypoglycemia, alcoholic ketoacidosis.

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22
Q

Complications of chronic alcoholism or binge drinking…

A

EtOH-induced hypoglycemia, alcoholic ketoacidosis. Note AKA can occur with ketoacidosis (met acidosis), hyperventilation (resp alk), and protracted emesis (met alk).

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23
Q

Chemical sedation in combative EtOHic.

A

Haloperidol, sedation without airways compromise or respiratory depression.

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24
Q

Wernicke-Korsakoff syndrome?

Ddx and Tx

A

Ddx (2 of following):

  • Dietary deficiencies.
  • Oculomotor abnormalities.
  • Cerebellar dysfunction.
  • AMS or mild memory impairment.

Tx - Thiamine IV + Mg

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25
Q

Methanol v. Ethylene Glycol Poisoning - Metabolism and Treatment

A

Methanol –> (ADH) –> formaldehyde TOXIC –> formic acid –> (folate) –> CO2 + H2O NON-TOXIC.

Methanol –> (ADH) –> glycolic acid TOXIC –> (thiamine, VitB6/pyridoxine) –> metabolites NON-TOXIC.

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26
Q

Methanol Poisoning - Ocular Toxicity

A

Retinal edema, hyperemia of disc, decreased visual acuity.

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27
Q

Anion Gap

Osmolal Gap

A

Na – (HCO3- + Cl-), nml 6-10.

2*Na + glucose/18 + BUN/2.8 + ethanol?4.3, positive is > 10 mOsm.

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28
Q

Methanol & Ethylene Glycol Poisoning - Treatment

A

Airway, sodium bicarb, antidotes –ethanol & 4-methylpyrazole (4-MP) – competitively block conversion to toxic metabolites.

Give ethanol/fomepizole (saturate ADH) + folate or thiamine/VitB6 +/– hemodialysis?

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29
Q

Dose of 4-MP…

A

15 mg/kg q12h; increased to 15 mg/kg q4h during dialysis. Treat for 48 hr.

30
Q

Indications for dialysis methanol/ethylene glycol?

A

Blood level > 50 mg/dL (or > 25 mg/dL), metabolic acidosis refractory to treatment, pending renal failure, visual symptoms in methanol ODl.

31
Q

Salicylate OD

  • Minimal Acute Toxic Dose
  • S/s
  • Labs
A
  • 150 mg/kg
  • N/V, tinnitus, vertigo, fever, diaphoresis, confusion, hyperventilation, pulm edema –> delirium, seizures, coma.
  • Salicylate levels, time 0, 6h, etc.
  • Acute respiratory alkalosis –> 12-24 hr –> anion gap metabolic acidosis.
32
Q

Salicylate OD

  • Treatment
  • Indications for Dialysis
A
  • Alkaline diuresis (IV bicarb). Activated charcoal + cathartic; lavage if w/in several hrs of ingestion. Cool, give K+, give D50, O2/CPAP/BiPAP/ET+PEEP (pulmonary edema).
  • Dialysis if… refractory metabolic acidosis (pH < 7.1), renal failure, CP dysfunction (pulm edema, dysrhythmias, cardiac arrest), CNS dysfunction (coma, seizures, cerebral edema), acute level > 130 mg/dL at 6 hr post-ingestion.
33
Q

Salicylate OD

Pt appears to be getting worse but blood levels are decreasing - Why?

A

Blood levels X tissue levels. In acidic blood, ASA remains un-ionized and more can penetrate the BBB.

34
Q

4 Phases of APAP Toxicity

- Time, S/s, Labs

A
  1. < 24 hr –Asymptomatic; anorexia, N/V, diaphoresis –toxic APAP level.
  2. 24-72 hr –RUQ pain –mild inc. LFTs.
  3. 3-5 days – N/V, jaundice, encephalopathy, oliguria–large inc. LFTs, coagulopathy, azotemia, hypoglycemia, hypoPO4.

4/. 1 week –Potentially, gradual resolution w/ improvement in lab values.

35
Q

What is rapidly depleted in APAP OD that accounts for accumulation of toxic metabolites?

A

Glutathione

36
Q

Prediction of hepatotoxicity in APAP OD.

A

> 7.5 gm adult, 140 mg/kg child.

Rumack-Matthew nomogram.

37
Q

APAP Antidote

A

NAC (glutathione substitute), best if administered w/in 10 hrs.

Dilute 1:5 with water (20% soln). Loading dose 140 mg/kg, maintenance 70 mg/kg q4h for 17 additional doses. Vomit w/in 1 hour of dose? Give dose again. Can also give IV but may cause N/V, flushing –slow infusion, give Benadryl; angioedema/anaphylaxis – stop infusion, Benadryl, steroids, Epi.

38
Q

Rabies PEP

A
  1. Clean wound.
    • 20 IU/kg human rabies IG (50% in wound, 50% in gluteal muscle).
    • 1 mL vaccine in deltoid muscle or anterolateral thigh on days 0, 3, 7, and 14.
39
Q

“Fight Bite”

A

Strep > PCN-resistant S. aureus.

Eikenella - PCN or ampicillin; resistant to semi-synthetic penicillins, clinda, 1st gen cephalosporins.

40
Q

Why is smoke inhalation dangerous?

A

CO & CO2 –> hypoxemia. Toxic gases.

41
Q

4 Stages of Smoke Inhalation

A
  1. 1-12 hr, acute respiratory distress (bronchospasm, edema).
  2. 6-72 hr, ARDS (noncardiogenic pulmonary edema).
  3. 60-120 hr, strangulation 2/2 cervical eschar formation.
  4. 72 hr+, pneumonia (S. aureus, Pseudomonas, Gm negative).
42
Q

First Signs of Smoke Inhalation

A

Cough, sputum production, hoarseness.

43
Q

Smoke Inhalation Evaluation/Treatment
Asymptomatic
Symptomatic

A

Asymp - Observe for a few hrs, struct return precautions (cough, SOB, fever).
Symp - Confirm with bronchoscopy.

Higher fluid requirement but more likely to develop pulm edema - Gide fluid resuscitation on clinical appearance.

Do NOT need a CXR - will be negative at first.

44
Q

CO Inhalation

  • Cause
  • Evaluation
  • Treatment
A
  • Fire in enclosed space.
  • CO level.
  • Non-rebreather high flow mask O2 (decreases t1/2 from 4-5h to 1h); HBO if pregnant with CO > 15, any neuro abnormality, any cardiac ischemia.
45
Q

Cyanide Inhalation

  • Cause
  • Evaluation
  • Treatment
A
  • Smoke from burning furniture or fabric (wool, silk, polyurethane).
  • Increased lactate.
  • HBO, Lilly cyanide antidote kit, hydroxocobalamin.

Hydroxocobalamin = VitB12; combined with cyanide to form non-toxic cyanocobalamin.

46
Q

Naloxone Dose

Duration of Action?

A

CNS depression only… 0.2-0.4 mg initial dose, repeat up to 2 mg (up to 10 mg for some synthetics?).

Apneic…2 mg initial dose.

Chronic user? Infuse 0.1 mg; wakes pt without inducing withdrawal.

Note: 0.8 mg IM = 0.4 mg IV

*** Duration of action = 40 - 75 min; need repeat dosing!!!!

47
Q

Disposition in Opiate/Opioid OD + Naloxone?

A 
After last dose of naloxone...
Heroin, 4h
Injection of Long-Term Opioids, 4-8h
Ingestion of Long-Term Opioids, 24h+
Complications (inadequate ventilation, etc.), admit.
48
Q

Opioid Withdrawal

  • S/s
  • Treatment
A
  • Yawning, anxiety, lacrimation, rhinorrhea, diaphoresis, mydriasis, N/V, diarrhea, piloerection, abd pain, myalgia.
  • Symptomatic - IVF, sedation, antiemetics, antidiarrheal agents +/– clonidine 0.1-0.2 mg PO.
49
Q

Body Stuffers v. Packers, Treatment

A

Suffers - Activated charcoal.

Packers - Xray/CT, activated charcoal, polyethylene glycol soln (Golytely) / enemas –> repeat CT +/– surgery.

50
Q

Other Considerations in Synthetic Opioid OD

A

APAP level.

51
Q

Other Complications of Opioid OD

A

Non-cardiogenic pulm edema (pink frothy sputum, cyanosis, rales, bilateral alveolar infiltrates).

52
Q

Sedative/Hypnotic OD, Treatment

A

Supportive! ABCDs, activated charcoal (1 gm/kg w/in 1 hr), exclude other causes of presentation.

53
Q

BZD/Zolpidem Antidote

A

Flumazenil, 0.2-0.5 mg IV repeat up to 5 mg.

ACUTE, SINGLE-AGENT ODs ONLY! Can induce seizures in multi-agent ingestions or chronic BZD users.

54
Q

Complications of Mushrooms

A

GI distress, hepatic failure, seizures.

55
Q

Hallucinogens

  • Complications
  • Treatment
A
  • Hyperthermia, met acidosis, HTN, seizures, dysrhythmias, rhabdomyolysis.
  • Calm environment, supportive care; BZD for seizures and agitation; antipsychotics for hallucinations and psychosis.
56
Q

Treatment for Cocaine-Induced CP

A

PTX, pneumomediastinum, MI.

+ BZD

57
Q

Complications of Methamphetamines and MDMA/Ecstasy (designer amphetamine)

A

HTN, dysrhythmia, intracranial hemorrhage, seizures, hyperthermia. Especially, if taken during rave in case of MDMA. Long-term neurotoxicity in chronic MDMA use. MDMA associated with severe hypoNa+ (increased H2O intake during rave, drug-induced secretion of ADH).

58
Q

Treatment Stimulant Toxicity, esp. HTN

A

3C’s

  • Calm - BZD (agitation, seizures)
  • Cool - cooling blankets, cool IVF
  • Complications - evaluate for potential complications

HTN? BZD. Severe HTN emergency? BZD + nitroglycerin. +/– Phentolamine, nitroprusside, CCB rarely as needed,

*** AVOID Beta-Blockers!!! Dogma: Allows for unopposed-alpha stimulation –> severe HTN, coronary artery vasoconstriction.

59
Q

Cocaine + EtOH?

A

Depresses myocardial contractility.

60
Q

Stimulant-Induced OTD (Occult Triad of Death)

A

Acidemia, rhabdo, pyrexia.

61
Q

Peds - Lomotil

A

Anticholinergic –> opioid toxidrome.

62
Q

Peds - Toxic Dose of TCA

A

> /= 15 mg/kg, approx. one adult dose.

63
Q

Peds - Sulfonylura OD

A

Octreotide (antidote) + dextrose (as needed to maintain blood glucose)

64
Q

Pads - Toxic Dose of Salicylates (ASA & OIL OF WINTERGREEN aka methyl salicylate)

A

BOTH pends and adults…acute toxicity at 150 mg/kg, serious toxicity at 300 mg/kg.

65
Q
  • Brady + HTN
A
  • Pre-Synaptic Alpha2 Agonists (clonidine, oxymetazoline, tetrahydrozoline) - transient.
66
Q
  • Brady + HypoTN + Narrow QRS
A
  • Pre-Synaptic Alpha2 Agonists (clonidine, oxymetazoline, tetrahydrozoline).
  • Beta-blockers, CCB, cardiac glycosides.
  • Sedative/hypnotics, opioids, BZDs/barbs (minimal).
  • Organophosphates and carbamates.
67
Q
  • Brady + HypoTN + Wide QRS
A
  • Lidocaine, tocainide.
  • B-blockers w/ Na-channel effects (propranolol, acebutolol, metoprolol).
  • CCBs, cardiac glycosides - severe toxicity.
  • Propafenone, flecainide.
  • Quinidine, procainamide, disopyramide.

** Hyperkalemia from cardiac glycosides, BB, and K+sparing diuretics.

68
Q

Antidote for Na+ channel blockade.

A

Na bicarbonate 1-2 mEq/kg bolus; x2 if QRs fails to narrow. + Hyperventilation to pH 7.5 and hypertonic saline.

+/– IVF/vasopressors for HTN, BZD for seizures, ET tube for AMS.

69
Q

Tx CCB OD

A

HypoTN - IVF boluses.
Brady - atropine or pacing; inotropes (dopamine, NE, Epi).
Calcium gluconate, calcium chloride (central line or large IV; risk of vein necrosis).

70
Q
  • Tachy + HypoTN + Wide QRS
A

TCAs

71
Q

Summarize CCB/BB OD Tx

A

Supportive, symptomatic. ABCs, IVF, pressers. Atropone, glucagon, Ca, high-dose insulin.

72
Q

Acute digoxin toxicity. Dose needed to cause, symptoms, treatment.

A

1 mg in kid, 3 mg in adult –> bradycardia, heart block, systemic hyperkalemia.

Symptomatic Brady, complete heart block, VTach, VFib –> digoxin immune Fab.

Emergency Medicine (4 decks)

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