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Toxicology Flashcards

1
Q 
Charcoal, optimal ratio of charcoal: toxin
poorly bound (4)
A 
10:1
small molecules (lithium, iron, cyanide), hydrocarbons, alcohol, acid/alkalai
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2
Q

Antidotes

BAL, DMS (3)

FFP / Vit K / PCCs

Calcium, glucagon, gluc/insulin, intralipids

Sodium nitrite, sodium thiosulfate, hydroxycobalamine

A

Arsenic, mercury, lead (add EDTA)
warfarin
calcium channel blocker

cyanide

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3
Q

Antidote 2

Alkaline diuresis, hemodialysis (2)

Bicarbonate, ethanol, dialysis, 4-MP (2)

Glucagon, intralipids

Protamine

A

Aspirin, barbiturates
ethylene glycol, methanol
beta blocker
heparin

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4
Q

Antidote 3

pyridoxine (a.k.a.)
sodium bicarbonate, intra-lipids
methylene blue (2)
calcium, magnesium
A

INH; vitamin B6
TCA
nitrates, met hemoglobin EMEA
hydrofluoric acid

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5
Q

Dereroxamine

atropine, 2-PAM

octreotide and two other things

Physostigmine

A

Iron
organophosphate (cholinergic and central nicotinic)
Oral hypoglycemic along with glucagon and glucose

anticholinergics if severe (but not for TCA)

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6
Q

Anion gap formula

MUDPILES pneumonic

A

(Na) - (Cl + CO2), normal < 12

MUDPILES pneumonic - causes of anion gap metabolic acidosis

M Methanol, metformin, massive ingestions

U Uremia

D DKA

P Paraldehyde

I Iron, INH

L Lactic acidosis (CO, CN)

E Ethylene glycol

S Salicylates

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7
Q

Increased osmolar gap (3)

false positives
amphetamines
TCAs
PCP

A

Alcohol toxic (acetone, isopropanol, methanol, ethylene glycol) or not, mannitol, ketoacidosis

Osmolar gap = Actual - Calculated (nl 285-295) = 2 Na + BUN/18 + Glu/18 + EtOH/4.6

amphetamines: Sudafed
TCAs: cyclobenzaprine, carbamazepine, diphenhydramine, phenothiazines
PCP: ketamine, dextromethorphan

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8
Q

Drug levels helpful when predictive of subsequent toxicity or guides specific therapy (5)

A

Iron, lithium, acetaminophen, aspirin, digoxin

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9
Q

Anticholinergic toxidrome

classic examples (5)

key difference with similar toxidrome:

A

“Hot as hell, blind as a bat, dry as a bone, red as a beet, mad as a hatter”; Dry, flushed skin, dry mucus membranes, mydriasis, decreased bowel sounds, urinary retention

examples: atropine, antihistamine, Jimsonweed, Parkinson’s medications (L dopa), , phenothiazines, TCAs

key difference: sympathomimetic has diaphoresis rather than dry skin

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10
Q

Anticholinergic treatments of

Classic toxidrome (Mad as hatter…..) normal and if severe

wide complex tachycardia
torsade de pointes

A

Benzodiazepines, Physostigmine if very severe and no TCA
bicarbonate
magnesium, overdrive pacing

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11
Q
A
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12
Q

Sympathomimetic treatment

Mimic of opiod OD

A

Benzodiazepine

Clonidine

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13
Q

Cholinergic toxidrome

Key examples (2) and mechanism

muscarinic effects mnemonic

A

Organophosphate insecticides, chemical warfare agents, some mushrooms
inhibit cholinesterases -> increases acetylcholine

SLUDGEM- Bs

salivation, lacrimation, urination, diarrhea, GI distress, emesis, miosis

Bs: –Bradycardia, Bronchospasm, Bronchorrhea

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14
Q

Cholinergic toxidrome

Nicotinic effects (3)

tx

A

Muscle weakness, fasciculations, respiratory failure

atropine, 2-PAM (Pralidoxime)

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15
Q

Withdrawal syndromes
common treatment for alcohol, barbiturates, benzodiazepines, cocaine, clonidine

A

Benzodiazepines, clonidine

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16
Q

Tylenol tox

mechanism

stages

A

Saturated normal metabolism shifts to minor pathway cytochrome P450 -> when glutathione depletes, toxic free radical metabolits NAPQI accumulates and damages hepatocytes

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17
Q

Tylenol tox

toxic ingestion mg/kg; grams average adult

4 hour toxic level

Mech

Use > 24 hours presentation?

A

140 mg per kilo, 7 to 10 g
140 at four hours
provides necessary cofactor to metabolize NAPQI

>24 hours: yes

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18
Q

Wernicke’s encephalopathy sx (4)

Korsakoff’s psychosis sx (2)

A

Wernicke’s encephalopathy: Oculomotor crisis

CN VI palsy (lateral rectus), nystagmus, ataxia, global confusion

Korsakoff’s psychosis: Retrograde amnesia, confabulation

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19
Q

Methanol
metabolic presentation

Pathogenesis
Key symptom

Other sx (3)

A

Anion gap metabolic acidosis with increased osmolar gap

alcohol dehydrogenase creates formaldehyde and formic acid

Visual changes/blindness

Seizures, resp failure, pancreatitis

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20
Q

Methanol

Antidote (2)

Adjuncts if refractory to above (2)

A

Fomepizole (4MP) -> prevents conversion leading to renal excretion

Ethanol (preferentially metabolized)

Dialysis, bicarbonate

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21
Q

Ethylene glycol
toxidrome key:
mechanism of toxicity

A

toxidrome key: altered mental status + elevated anion and osmolar gap acidosis
mechanism of toxicity: toxic metabolites oxalic acid and glycolic acid

other findings: renal failure, hematuria, hypocalcemia; calcium oxalate crystals in the urine

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22
Q

Ethylene glycol

treatment similar to other toxic alcohols
unique treatment (2)

supportive treatment

A

treatment similar to other toxic alcohols: fomepizole (4MP)
unique treatment: pyridoxine, thiamine

supportive treatment: bicarbonate four acidosis, dialysis for severe acidosis and/or high blood levels

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23
Q

Isopropyl alcohol

toxidrome compared to other toxic alcohols

symptoms (4)
treatment (2) and how differenent from other toxic alcohols

A

toxidrome compared to other toxic alcohols: ketosis /elevated osmolar gap WITHOUT anion gap or acidosis

symptoms: altered mental status plus hemorrhagic gastritis, pulmonary edema, hypotension
treatment: supportive care +/- hemodialysis

Tx difference: NO role for fomepizole or EtOH since metabolite less toxic than the toxin

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24
Q

Cocaine
similar toxidromes with key difference

A

Similar to anticholinergic toxidrome

cocaine: diaphoresis, dilated pupils

anticholinergic: skin dry instead of sweaty
cholinergic: pupils pinpoint instead of dilated

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25
Toxicology pearls bradycardia pneumonic (6) tachycardia pneumonic (4)
**Bradycardia** P Propranolol (beta blockers), poppies (opioids) A Anticholinesterase drugs C Clonidine, calcium channel blockers E Ethanol, other alcohols D Digoxin **Tachycardia** F Freebase (cocaine) A Anticholinergics, antihistamines, amphetamines S Sympathomimetics, solvent abuse T Theophylline
26
Toxicology pearls hyperthermia (4) hypothermia (5)
**Hyperthermia** N NMS, nicotine A Antihistamines S Salicylates, sympathomimetics, Serotonin syndrome A Anticholinergics, antidepressants **Hypothermia** C Carbon monoxide O Oral hypoglycemics, insulin O Opioids L Liquor S Sedatives, hypnotics
27
Toxicology pearls hypotension (5) hypertension (6)
**hypotension** C Carbon monoxide O Oral hypoglycemics, insulin O Opioids L Liquor S Sedatives, hypnotics **hypertension** C Clonidine, calcium channel blockers R Reserpine (antihypertensive agents) A Antidepressants, aminophylline S Sedatives, hypnotics H Heroin (opioids)
28
Toxicology pearls hypoventilation (4) hyperventilation (4)
**Hypoventilation** S Sedatives, hypnotics L Liquor O Opioids W Weed (marijuana) **Hyperventilation** P PCP, pneumonitis (chemical) A ASA (salicylates) N Noncardiogenic pulmonary edema T Toxic metabolic acidosis
29
Toxicology paroles Miosis (4) Mydriasis
NMiosis C Cholinergics, clonidine O Opioids, organophosphates P Phenothiazines, pilocarpine, pontine bleed S Sedatives, hypnotics
30
Toxicology Pearls Red Skin (2-3) Blue Skin (2 + expand)
Red skin: Anticholinergics, boric acid, carbon monoxide Blue skin: Cyanosis, methemoglobinemia, (nitrates, nitrites, aniline dyes, dapsone, phenazopyridine)
31
Toxicology Pearls - odors Bitter almonds or “silver polish” Mothballs Garlic (3) Wintergreen: Methyl salicylate Carrots Gasoline Fruity (2) Pears
Bitter almonds or “silver polish”: Cyanide Mothballs: Camphor Garlic: Arsenic, organophosphate, DMSO Rotten eggs: Sulfur dioxide, hydrogen sulfide Wintergreen: Methyl salicylate Peanuts: Vacor (rat poison) Carrots: Water hemlock Gasoline: Hydrocarbons Fruity: DKA, isopropanol Pears: Chloral hydrate
32
Toxicology Pearls Radioopaque drugs (5)
COINS C Chloral hydrate, Cocaine packets O Opiate packets I Iron, (Heavy metal: Pb, As, Hg) N Neuroleptic agents S Sustained release products, enteric coated preparations
33
Toxicology pearls noncardiogenic pulmonary edema
MOPS M Meprobamate, methadone O Opioids P Phenobarbital, propoxyphene S Salicylates
34
Toxicology pearls multidose charcoal indications (4) all bowel irrigation indications (2)
multidose charcoal indications: phenobarbital, sustained-release drugs, salicylates, theophylline all bowel irrigation indications: sustained-release drugs not absorbed by charcoal, body packing
35
Toxicology pearls appropriate for dialysis (7)
Toxic alcohols (methanol, isopropyl alcohol, ethylene glycol), lithium, salicylate, theophylline, phenobarbital
36
Delayed-release toxicity - many, review
Delayed toxicity – Acetaminophen – Digoxin – Ethylene glycol – Heavy metals – Methanol – Mushrooms – Narcotics – Iron – Salicylates – Slow release compounds
37
Anticholinergics/antihistamine classic cause of severe symptoms and other 2 parts of this drugs toxidrome EKG changes
TCA -\> also causes sodium channel blockade. CNS depression EKG: tachycardia, QRS wide, dominant R' in AVR
38
TCA overdose treatment decontamination? Drug for EKG changes Drug for ventricular dysrhythmia
decontamination: yes, multidose charcoal, whole bowel irrigation Drug for EKG changes: bicarbonate Drug for ventricular dysrhythmia: lidocaine
39
Barbiturates toxidrome similar to treatment (4)
toxidrome similar to opiates treatment: charcoal, gastric lavage, dialysis, urinary alkalinization
40
Beta-blocker/CCB treatment (3-4) unexpected's systemic toxicity from this form
treatment: insulin/D5, glucagon, intralipids, calcium for CCB unexpected's systemic toxicity from this form: timolol eye drops
41
Carbon monoxide poisoning mechanism lab abnormality to suspect associated toxidrome SaO2 and PaO2 level delayed sequela
CO has 250 times the affinity for 02 and inhibits the release of oxygen from hemoglobin (why there is not significant cyanosis; O2 present but bound) severe metabolic acidosis should suggest associated cyanide SaO2 and PaO2 level: often normal delayed: neuropsychiatric syndrome, HBO may prevent
42
Caustic ingestion acid necrosis type alkali necrosis type Which is worse and why? Predictive value of oropharyngeal burns with alkali
Acid: coagulation alkali: liquefaction alkali since liquefaction necrosis facilitates progression whereas eschar stops progression of coagulation necrosis predictive value: none
43
Caustic ingestions dilute? Hydrofluoric acid treatment solid alkali treatment
dilute: generally not as this can induce vomiting Hydrofluoric acid treatment: magnesium citrate and milk solid alkali treatment: dilution with water or milk consider endoscopy
44
Clonidine mechanism toxidrome (3) mimics? Toxidrome treatment (3+1?)
mechanism: alpha adrenergic agonist toxidrome: hypotension, bradycardia, AMS mimics? Opiate overdose treatment: fluids, atropine, pressers, naloxone may be helpful
45
Cyanide odor signature lab abnormality ``` other sx (2+) PaO2 and SaO2 levels ``` medication -induced cause treatment principle and medication
Bitter almonds large AG metabolic acidosis altered mental status,CV collapse normal nitroprusside induce methemoglobinanemia with hydroxocobalamin (or amyl nitrate, sodium nitrate/thiosulfate etc)
46
Digoxin toxicity electrolyte abnormality? signature EKG abnormality and most common Antidote, acute and chronic contraindicated hyperkalemia treatment
Hyperkalemia, hyponatremia (from inhibition of the Na-K pump) AV blocks, PVCs Digibind 10 and 6 vials; 20 if severe calcium (increases toxicity)
47
Psychedelics - mechanism hydrocarbons - often cause gastric emptying?
Serotonin 5HT2 agonist aspiration pneumonitis no except when CHAMP Camphor Halogenated (carbon tet, PVC, vinyl chloride) Aromatic (benzene, toluene, xylene) Metals (leaded gas) Pesticides
48
Hydrogen fluoride mechanism physical exam caveat treatment hydrogen sulfide treatment
Potent inorganic acid used in glass etching May have deep injuries despite normal appearing skin calcium gluconate gel, titrate to pain hydrogen sulfide treatment: use methylene blue for MetHgb; simllar mech to CO
49
Intractable seizures classic tox cause and tx Iron poisoning effects (3) and timing diagnosis treatment (2)
INH overdose, B6 - pyridoxine G.I. bleed, inhibits aerobic metabolism, CV collpase/ARF immediate and delayed phases 4 hour iron level; deferoxamine
50
Lead poisoning ``` timing, effective age classic symptom (+ others) ```
Chronic, children peripheral neuropathy leading to rest drop, also: ha, encephalopathy, belly pain
51
Lithium tox diagnosis treatment (3+) Mercury from thermometer toxic?
Symptoms plus a positive level (actual # not reliable) aggressive hydration, dialysis, lavage, kayexalate Mercury from thermometer toxic? NO
52
MAOI inhibitors mechanism toxic complication types (2) and drugs for 2nd type
Inhibits breakdown of catecholamines (norepi, epi, serotonin) hypertensive crisis: with amphetamines, wine, cheese, fava beans serotonin syndrome/severe hypothermia: meperidine and dextromethorphan
53
Methhemoglobinemia mechanism signature finding and blood color classic causes PaO2 level? Antidote
MetHgb unable to bind O2 hypoxia unresponsive to oxygen; chocolate brown causes: nitrates, benzocaine, dapone, pyridium PaO2: normal methylene blue
54
Mushroom toxicity timing Pearl specific for pictured species
Time from ingestion to symptom onset helps determine risk of significant toxicity –Symptoms within 2 hours of ingestion indicate benign course if only one type of mushroom ingested –Symptoms delayed more than 6 hours indicate a toxic ingestion with risk of hepatic and renal failure Amanita Phalloides: initial G.I. symptoms in 12 hours, then latent, then liver and renal failure in 1 to 2 days
55
Neuroleptics side effect categories (5) treatment (3)
Dystonia, Tardive dyskinesia, Akathesia, anticholinergic,Quinidine like (prolonged QT) benztropine/Cogentin, Benadryl, benzodiazepines
56
Neuroleptic malignant syndrome timing symptoms (3) lab clue treatment (3+)
Subacute onset AMS, hyperthermia, leadpipe rigidity elevated CK fever control, benzodiazepines, dantrolene, bromocriptine, paralysis
57
Naloxone - duration of action do non-sulfonylureas cause hypoglycemia? Metformin complication sulfonylureas antidote when severe
30 to 60 minutes no lactic acidosis octreotide
58
Organophosphates mechanism of actions (2) Toxidrome pneumonic
Inhibit cholinesterases; cholinergic toxidrome and nicotinic effects cholinergic: SLUDGE + killers Bs Nicotinic: weakness, fasciculations, respiratory failure Killer “B”s – Bradycardia, Bronchospasm, Bronchorrhea S – Salivation L – Lacrimation U – Urination D – Diarrhea G – Gastrointestinal upset E – Emesis
59
Tox, Rotary nystagmus = toxidrome for toxic plants deadly nightshade, Henbane, jimsonweed foxglove, Oleander, Lily of the Valley tobacco/cigarettes
PCP anticholinergic digitalis toxidrome Pictures - side 1 Jimsonweed, side 2 Foxglove cholinergic
60
Salicylates classic dyad other symptoms (3) treatment (2) product with high amount of salicylate
Anion gap metabolic acidosis, respiratory alkalosis other symptoms: tinnitus, pulmonary edema, hypoglycemia urinary alkalinization, dialysis oil of Wintergreen
61
Serotonin syndrome timing symptoms (with underlying categories) treatment (2)
Acute hyperthermia, altered mental status, myoclonus cooling, cyproheptadine Easiest way to distinguish from NMS is the acuity –CNS (altered mental status, coma, seizures) –Autonomic (hyperthermia, tachycardia, hypertension) –Neuromuscular (myoclonus, hyperkinesia)
62
Strychnine mechanism/syndrome
Blocks inhibition of postsynaptic brainstem glycine receptors and spinal cord motor neurons Results in CNS hyperstimulation
63
TCA overdose symptom categories (3)
Anticholinergic, CNS, cardiovascular ## Footnote Anticholinergic effects –Flushed skin, dry mouth, mydriasis, decreased bowel sounds, urinary retention CNS effects –Drowsiness, confusion, ataxia, delirium, seizures, coma Cardiovascular effects –Hypotension, tachycardia, wide QRS, V-tach, torsades –Right axis deviation (negative S in I, positive R in aVR)
64
-xabans; best test to assess activity Pradaxa reversal
Thrombin time praxabind

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