Toxicology

Question 1

First steps in acetaminophen overdose

Answer 1

1. Activated charcoal if within 4 hours of ingestion.

2. Acetaminophen level

Question 2

When is N-acetylcysteine given in acetaminophen overdose?

Answer 2

1. Level above treatment line of normogram or >10 ug/ml

2. Any evidence of liver injury

Question 3

Breath that smells of bitter almonds

Answer 3

Cyanide poisoning

Question 4

Medications that can lead to acquired methemoglobinemia

Treatment?

Answer 4

1. Topical anesthetics like benzocaine
2. Nitrates
3. Dapsone
   Treatment: methylene blue (to reduce)

Question 5

Oxygen saturation gap between pulse-ox (low) and ABG (high)

Answer 5

Acquired methemolobinemia

CO poisoning will also have high O2 sat on ABG, but pulse-ox saturation will be fairly high (90s) as well

Question 6

Signs of marijuana intoxication on physical exam

Answer 6

Dry mouth, conjunctival injection, normal pupils

Question 7

What if a patient is crazy like on PCP but u-tox is negative and they don’t get better for a while?

Answer 7

Bath salts

Question 8

How can you differentiate between alcohol and benzos on physical exam?

Answer 8

Alcohol causes nystagmus, benzos do not

Question 9

How can you differentiate between opioids and benzos on physical exam.

Answer 9

Opioids lead to pupillary constriction and respiratory depression, benzos do not

Question 10

Toxicity of ethylene glycol

Answer 10

1. Hypocalcemia (precipitates with oxalate)

2. Flank pain and AKI (calcium oxalate crystals)

Question 11

Treatment for alcohol withdrawal in inpatient setting

Answer 11

Lorazepam

Question 12

Visual hallucinations within the first 48 hours after hospitalization

Answer 12

Alcoholic hallucinosis (although can be auditory or tactile - sensorium is intact and vitals normal, unlike DTs)

Question 13

Capillary blood lead level shows high levels. What is the next step?

Answer 13

Confirmatory venous blood level.

Question 14

Treatment for elevated blood lead levels

Answer 14

<45: repeat in 1 month
45-60: DMSA a.k.a. succimer
>60: Dimercaprol (British anti-Lewisite) and EDTA

Question 15

Key side effect(s) of cyclosporine

Answer 15

1. Nephrotoxicity
2. Neurotoxicity (HA, vision changes, seizures, tremors, akinetic mutism)
3. Gingival hypertrophy and hirsuitism (not seen with tacrolimus)
   (Others: HTN, glucose intolerance, GI upset, infection, malignancy)

Question 16

Key side effect(s) ot tarcolimus

Answer 16

1. Nephrotoxicity
2. Neurotoxicity (HA, vision changes, seizures, tremors, akinetic mutism)
   Unlike cyclosporine, gingival hypertrophy and hirsuitism are absent.

Question 17

Key side effect(s) of azathioprine

Answer 17

1. Leukopenia
2. Hepatotoxicity
   (Also dose-related diarrhea

Question 18

Key side effect(s) of mycophenolate

Answer 18

Bone Marrow suppression