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PEM exam > Toxicology > Flashcards

Toxicology Flashcards

1
Q

Drugs that cause hypoglycemia

A
  1. Ethanol
  2. Oral hypoglycemics
  3. B blockers
  4. Salicylates
  5. Insulin
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2
Q

Naloxone dose

A

0.4-2 mg dose every 2 minutes up to 8-10 mg for patients of all ages (start with 2 if acute use, 0.2 if chronic drug user).

Previous recommendations was 0.01-0.1 mg/kg/dose.

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3
Q

Naloxone indications

A
  1. Opioid exposure
  2. Cough medicines (codeine, dextrometorphan)
  3. Antidiarrheal agents (paregoric, diphenoxylate)
  4. partially naloxone-responsive anti hypertensives (clonidine)
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4
Q

Why not use flumazenil empirically?

A

Precipitates seizures and withdrawal

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5
Q

Calculated osmolarity formula

A

2xNa + glucose + BUN

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6
Q

MUDPILES

metabolic acidosis with high anion gap

A 
Methanol, metformin
Uremia
DKA or other ketoacidosis
Paraldehyde
Isoniazide, iron, inborn error of metabolism, ibuprofen
Ethylene glycol
Salicylate, seizures
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7
Q

Substances causing difference between measured and calculated serum osmolarity

A

Ethanol
Isopropanolol
Methanol
Ethylene glycol

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8
Q

Substances poorly absorbed by activated charcoal

A 
Common electrolytes
Metals (iron, lead, lithium, arsenic)
Mineral acids or bases
Alcohols
Cyanide
Most solvents
Most water insoluble compounds (eg hydrocarbons)
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9
Q

Activated charcoal dose

A

1g/kg to max of 50-100 g

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10
Q

Medications with antidotes

A
  1. TCAs : sodium bicarb
  2. Cyanide : hydroxycobalamin or amyl nitrite inhalation then sodium nitrite then sodium thiosulfate
  3. Cholinesterase inhibitors (organophosphates): atropine, pralidoxime
  4. Ethylene glycol and methanol: ethanol or fomepizole
  5. Hypoglicemia (ethanol, salicilate, oral hypoglycemic): dextrose
  6. Methemoglobinemia : methylene blue
  7. Carbon monoxide: oxygen
  8. Benzos: flumazenil
  9. INH and gyrometra mushroom: pyridoxine
  10. Digoxin : digibind (digoxin immune antibody)
  11. Lidocaine, local anesthetics: IV lipid emulsion
  12. Opioids: naloxone
  13. Acetaminophen : N-acetylcisteine
  14. Ca channel blocker: calcium chloride/gluconate, insulin and glucose
  15. Beta blocker: glucagon
  16. Fluoride: calcium gluconate
  17. Heavy metals: dimercaprol, EDTA, DMSA
  18. Iron: deferoxamine
  19. Sulfonylurea: octreotide
  20. Warfarin: vit K
  21. Phenothiazine (dystonia): diphenhydramine
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11
Q

Drugs that can be hemodialyzed

A
  1. Salicylate
  2. Lithium
  3. Ethylene glycol
  4. Methanol
  5. Phenobarbital
  6. Theophylline
  7. Paraquat (herbicide)
  8. Others (valproic acid, methotrexate, metformin induced lactic acidosis)
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12
Q

Salicylate toxicity. Effects?

A
  1. Respiratory alkalosis (causes tachypnea)
  2. Metabolic acidosis
  3. Coagulopathy (platelet dysfunction and liver damage)
  4. Neuro: seizures, coma
  5. Electrolyte abnormalities: glucose (high or low), Sodium (high or low), potassium (low).
  6. Tinnitus or change in hearing
  7. Pulmonary edema
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13
Q

Salicylate toxicity. Classic gas?

A

pH 7.41-7.55
PCO2 <30
Bicarb 15-20

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14
Q

Salicylate toxicity. Treatment?

A
  1. GI decontamination!!! Even up to 6 hours and sometimes later. Repeated doses of charcoal (MDAC multi dose activated charcoal). Enteric coated can be released even after 24-48h!
  2. Na bicarb infusion to alkalinize urine (5% dextrose with bicarb and potassium IV. Aim for urine output of 1-2 ml/kg/hr and pH 7.45-7.50 until clinically better and serum salicylate <30 mg/dL). Aim for urine pH 8-9. Start if CNS symptoms (tinnitus included), acidosis, or salicylate level >30. (3 amps of bicarb in 1l bag D10W)
  3. Consider dialysis. Call nephro right away!
  4. Try to avoid intubation!! Respiratory alkalosis is actually helping. Once pH becomes acidotic it releases salicylate into the brain!
  5. Dextrose (D5W or D10W). You can have CSF hypoglycaemia with serum euglycemia.
  6. Replace K. (Can add 40 KCl to bicarb)
  7. Get salicylate level q1h.
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15
Q

Drug induced seizures treatment

A
  1. First line benzos, benzos, benzos
  2. 2nd line phenobarbital (phenytoin and phosphenytoin don’t work, they are sodium channel blockers)
  3. Consider other causes. Hyponatremia, hypoglycemia, hypoxia). INH can cause seizures, treat with B6.
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16
Q

Causes of vision loss or changes

A
  1. Methanol
  2. Metabolic acidosis (DKA, metformin, alcohol induced ketoacidosis)
  3. Quinine
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17
Q

Calcium channel blocker effects

A
  1. Neuro: coma, seizures
  2. Cardiovascular: bradycardia, hypotension, AV node conduction abnormalities (AV block, accelerated junctional rhythm)
  3. Metabolic: hyperglycemia, metabolic acidosis.
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18
Q

Beta blocker effects

A
  1. Neuro: seizures, coma
  2. Cardiovascular: bradycardia, hypotension
  3. Metabolic: hypoglycemia
  4. Respiratory: bronchospasm, especially if asthma.
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19
Q

Calcium channel blocker o/d treatment

A
  1. Gastric decontamination (charcoal)
  2. Atropine for bradycardia
  3. Fluid boluses and norepi for hypotension
  4. Calcium infusions
    0.2 mL/kg bolus of 10% ca chloride or
    0.6 mL/kg bolus of 10% ca gluconate x2-3
    (Adult doses:
    10 mL 10% Ca chloride
    30 mL 10% ca gluconate)
  5. Hyperinsulinemia-euglycemia: insulin 1 U/kg bolus then 0.5-1 U/kg/h
  6. Lipid emulsion
  7. Pacemaker
  8. ECMO
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20
Q

Beta blocker o/d treatment

A
  1. Gastric decontamination (charcoal)
  2. Atropine for bradycardia
  3. Fluid boluses and norepinephrine
  4. Glucagon (50-150 micrograms/kg boluses then infusion at same rate per hour. In adults 3-5 mg boluses to 10 mg followed by infusion at 2-5 mg/hour)
  5. Lipid emulsion
  6. Pacemaker
  7. ECMO
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21
Q

Clonidine o/d effects

A
  1. CNS: coma
  2. Cardiovascular: Hypotension, bradycardia
  3. Resp: depression
  4. Hypothermia
22
Q

Warfarin overdose treatment

A
  1. PO vitamin K: INR > 5 and able to tolerate PO, not actively bleeding.
  2. IV vitamin K : bleeding, INR>9
  3. Charcoal
23
Q

Clonidine treatment

A
  1. Airway
  2. Hypotension: fluids, pressors
  3. Naloxone 0.1-0.2 mg/kg boluses, need high doses (10 mg IV total)
  4. Charcoal
24
Q

Complications of deferoxamine?

A
  1. Pink/orange urine
  2. Hypotension
  3. Promotes growth of Yersinia enterocolitica and can lead to Yersinia sepsis.
25
Q

Iron overdose treatment

A
  1. GI decontamination: (charcoal does NOT bind). Gastric lavage with normal saline and/or whole bowel irrigation with Peglyte x 4-6 hours until rectal effluent clear.
  2. IV deferoxamine chelation. Max 15 mg/kg/h (max daily dose 360 mg/kg or 6 g).
  3. Supportive: IV fluids, pressors, benzos for seizures
26
Q

Iron overdose. Effects?

A
  1. Neuro: coma, seizures
  2. GI: local irritation (vomiting), ulcer, bleeding, hypotensive shock. Long term: strictures.
  3. Liver: necrosis, coagulopathy
  4. Renal: failure
  5. Metabolic: metabolic acidosis, leukocytosis, hyperglycemia
  6. Respiratory: failure.
27
Q

INH (isoniazid) overdose. Dose and triad of effects?

A 
Ingestion of >20 mg/kg or >1.5 g
Triad:
1. Seizures
2. Metabolic acidosis 
3. Coma
28
Q

Isoniazide overdose. Treatment

A
  1. Coma: intubation.
  2. GI decontamination: charcoal (consider multiple dose but high risk of seizures)
  3. Metabolic acidosis: bicarb
  4. Seizures: benzos, phenobarbital
  5. Pyridoxine (vit B6). Dose equal to ingested INH or 70 mg/kg (max 5g)
29
Q

Oral hypoglycemics. Effects?

A
  1. Sulfonylureas: hypoglycaemia

2. Biguanides (metformin): metabolic acidosis

30
Q

Biguanide (metformin) overdose. Treatment

A

Na bicarb

31
Q

Sulfonylurea (oral hypoglycemics like glyburide). Treatment.

A
  1. Glucose boluses
  2. 10-20% glucose infusion
  3. Octreotide 1-2 micrograms/kg/dose q 6-12h IV/SQ
32
Q

One pill killers

A
  1. Benzocaine (baby orajel) -> methemoglobinemia
  2. B-blockers
  3. Ca channel blockers
  4. Camphor (moth balls, vicks vaporub)
  5. Chloroquine
  6. Clonidine
  7. Lomotil (diphenoxylate)
  8. Hypoglycemics
  9. Lindane
  10. Salicylates (ASA, oil of wintergreen)
  11. Opioids
  12. Phenotiazines
  13. Quinidine
  14. Quinine
  15. Theophylline
  16. TCAs
33
Q

Methanol overdose. Treatment

A
  1. Sodium bicarb
  2. Folic acid
  3. Fomepizole or ethanol
34
Q

Methanol overdose. Effects?

A
  1. CNS: coma, seizures. Long term: paresthesias.
  2. Metabolic: acidosis
  3. Vision changes: blurry, blindness
  4. Multiorgan dysfunction: pancreatitis, cardiac arrythmias.
35
Q

Infant botulism. Presentation?

A
  1. Cranial nerve deficits (diplopia, ptosis)
  2. Constipation + poor feeding
  3. Progressive weakness, cranio->caudal.
  4. Bulbar symptoms: loss of gag reflex, suck
  5. Autonomic signs: decreased tearing and salivation, HR and BP changes, flushed skin
  6. 50% require intubation
36
Q

Infant botulism. Treatment

A
  1. Supportive. 50% require intubation
  2. BIG-IV (baby botulism IgG IV has type A and B. The adult one has 7 forms)
  3. No antibiotics
37
Q

TCA overdose. What are the ECG changes?

A
  1. QRS prolongation. Be concerned for arrythmias if >100 ms

2. R wave in aVR

38
Q

EKG in tox cases. What are you looking for?

A
  1. QRS prolongation (normal <90ms)
  2. The last 40 ms of your QRS may become more right axis deviated (so R is positive on right sided leads and negative on left sided leads). Classic for TCA.
  3. R on T
  4. Torsades
  5. PR prolongation
  6. Digoxin: salvador Dali’s mustache. Slurring of wave
  7. QT prolongation
39
Q

TCA overdose. Treatment

A
  1. Sodium bicarb!!!

2. If arrythmias: Lidocaine

40
Q

Carbamazepine overdose. Effects

A

Seizures
QRS prolongation
Decreased LOC

41
Q

Bupropion (wellbutrin) overdose. Effects?

A

Similar to amphetamines

  1. Seizures
  2. Tachycardia, hypertension
  3. In massive overdoses can prolong QT and widen QRS
42
Q

Haldol (haloperidol) overdose. Presentation?

A
  1. Anticholinergic: red, dry, full, hot, mad, blind (mydriasis, dilatation)
  2. Seizures
  3. Dystonia, choreoathetoid movement, akathisia, Extrapyramidal syndrome
  4. QT prolongation
  5. Neuroleptic malignant syndrome: muscle rigidity, mental status change, dysautonomia
43
Q

Methotrexate o/d. Tx

A
  1. Folic acid (Leucovorin, no other forms)
  2. Carboxypeptidase G2
  3. Activated charcoal
  4. Bicarbonate
44
Q

Local anesthetic toxicity. Treatment?

A

For lidocaine, bupivacaine toxicity:

Lipid emulsion 20% 1.5 ml/kg bolus over 30 minutes then infusion of 0.25 ml/kg/min. (Max 10-12 ml/kg).

45
Q

Inhalant (huffing or bagging). Agents?

A
  1. Hydrocarbons
  2. Nitrous oxide (whippets from whipped cream)
  3. Nitrites
46
Q

Inhalants (huffing, bagging). Complications?

A
  1. Euphoria
  2. Coma
  3. Respiratory arrest
  4. Sudden sniffing death (hydrocarbons make myocardium more reactive to catecholamines. Get V fib if startled)
  5. Methemoglobinemia
  6. Chronic use: renal tubular acidosis, hypoK, cerebral atrophy.
47
Q

Anticholinergic toxidrome treatment

A
  1. Supportive.
  2. Benzos for seizures
  3. Ventilate if coma
  4. Cardiac arrhythmias: treat with anti arrhythmics
  5. Physostigmine is agonist (1-2 mg over 5 min or 0.5 mg IV for smaller children). Can precipitate seizures, bronchospasm, bradycardia, hypotension
48
Q

Beta blocker overdose. Antidote?

A

Glucagon

49
Q

TCA overdose. Presentation?

A 
Altered mental status
Seizures
Wide complex tachycardia (QRS >100 ms) —> PVCs, Vtach
Myoclonic jerks
Metabolic acidosis
50
Q

TCA overdose. Antidote?

A

Bicarb

PEM exam (2 decks)

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