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ACEM Fellowship > Toxicology > Flashcards

Toxicology Flashcards

1
Q

Paracetamol - massive ingestion

A

> 30g

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2
Q

Phenytoin toxicity features

A

Neurological signs and symptoms predominate

  • cerebellar dysfunction
  • ataxia
  • tremor
  • involuntary movements

Cardiovascular effects are not associated with overdose at any dose of phenytoin.

Hypotension and arrythmia may be features of rapid administration of IV loading of phenytoin in status epilepticus.

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3
Q

Hunter Toxicity Criteria Decision Rule

A

Ingestion of serotonergic agent plus at least one of:

  • spontaneous clonus
  • inducible clonus AND (agitation or diaphoresis)
  • ocular clonus AND (agitation or diaphoresis)
  • tremor AND hyperreflexia
  • hypertonia AND temp > 38dC AND (ocular clonus or inducible clonus)
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4
Q

Serotonin syndrome treatment

A
  • Diazepam 0.1 - 0.3mg/kg for gentle sedation

ANTIDOTE
cyproheptadine 8mg PO

alternatives
olanzapine, chlorpromazine

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5
Q

Neuroleptic malignant syndrome Features

A
  • neuromuscular rigidity
  • altered mental status
  • autonomic instability
  • -> IN A PATIENT TAKING NEUROLEPTIC MEDS

CK elevation prominent

CNS
- confusion, delirium, stupor, coma

ANS
- hyperthermia, tachycardia, HTN, resp irregularities, cardiac dysrhythmias

Neuromuscular
- lead pipe rigidity, bradykinesia/akinesia, mutism, staring, abnormal involuntary movements

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6
Q

Neuroleptic malignant syndrome treatment

A

Bromocriptine (dopamine agonist)

Dantrolene

ECT

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7
Q

Anticholinergic syndrome treatment

A

Benzos for agitation

Avoid anticholinergic drugs eg olanzapine, droperidol

Antidote = physostigmine

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8
Q

Isoniazid

A

> 1.5g = symptoms
3g = seizures
10g = fatal

FEATURES

  • photophobia
  • mydriasis, ataxia
  • hyperreflexia
  • N&V
  • confusion
  • status seizures

INVESTIGATIONS

  • severe HAGMA, pH 6.8 - 7.3
  • high lactate

MANAGEMENT
- aggressive supportive care

ANTIDOTE
- Pyridoxine 5g if coma or seizures

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9
Q

NAC infusion

A
  1. 150mg/kg in 200mL over 15 mins
  2. 50mg/kg in 500mL over 4 hours
  3. 100mg/kg in 1000mL over 16 hours

(Dextrose 5%)

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10
Q

Salicylate toxic ingestion levels

A

< 150mg/kg = asymptomatic

> 300mg/kg = severe

> 500mg/kg = potentially lethal

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11
Q

Urinary alkalinisation

A

1-2mmol/kg NaHCO3 bolus, then IV infusion

target urine pH > 7.5

**Monitor serum K+ for hypokalaemia

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12
Q

Indications for DigiFab

A
  • cardiac arrest
  • life-threatening cardiac dysrhythmia
  • ingestion > 10mg adult or > 4mg child
  • serum level > 15nmol/ml
  • serum K > 5mmol/L

HOW MUCH?

  • 2 if chronic toxicity (observe response)
  • acute and stable = 5
  • acute and unstable = 10
  • cardiac arrest = 20
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13
Q

Treatment of lead toxicity

A

Chelation therapy

Sodium calcium edetate (EDTA)

Succimer - oral chelator

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14
Q

Iron - toxic ingestion levels

A

60-120mg/kg = systemic toxicity

> 120mg/kg = lethal

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15
Q

Iron toxicity - features

A

0-6 hours = GI upset, hypovolaemia

6-12 hours = pretty ok

12-48 hours = vasodilatory shock, HAGMA, hepatorenal failure

2-5 days = acute hepatic failure

2-6 weeks = cirrhotic liver disease, fibrosis

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16
Q

Iron toxicity - treatment

A

Early priority = restore circulating volume

Decontamination

  • Whole bowel irrigation if:
    1. > 60mg/kg ingested
    2. confirmed on XR
  • surgical or endoscopic retrieval if above indicated but impractical

Antidote
- desferrioxamine chelation therapy

17
Q

Indications for desferrioxamine chelation

A
  • systemic toxicity (shock, HAGMA, etc)
  • level > 90micromol/L at 4-6 hours

DOSE = 15mg/kg/hr

18
Q

What is Fluorosis?

A

Systemic toxicity from hydrofluoric acid exposure

  • hypocalcaemia and hypomagnesaemia –> tetany and prolonged QT
  • ventricular dysrhythmias and arrest
19
Q

ECG prognostication in TCA overdose

A

QRS > 100 –> seizures

QRS > 160 –> VT

20
Q

Treatment in TCA overdose

A
  • intubation and HYPERVENTILATION (pH 7.5 - 7.55)
  • NaHCO3- 100mmol (2mmol/kg) IV every 1-2 mins until perfusing rhythm restored
  • lignocaine 1-1.5mg/kg when pH >7.5 if ongoing ventricular dysrhythmia
  • fluids and vasopressors for hypotension

NB - procainamide, amiodarone, B blockers contraindicated

21
Q

Na channel toxicity: ECG features

A

tachycardia

prolonged/wide QRS interval

large terminal R in aVR and V1

increased R/S ratio > 0.7 in aVR

QT prolongation secondary to K+ blockade

right axis

22
Q

Treatment of local anaesthetic toxicity

A

Intravenous lipid emulsion

1-1.5ml/kg bolus, repeat 2-3x

0.25ml/kg/min IVI max 8ml/kg/min

23
Q

Treatment of methaemoglobinaemia

A

Methylene Blue
- if MetHb > 20% and symptomatic

1-2ml/kg slow push

usually a single dose

Associated with benzocaine, lignocaine, prilocaine. More likely in kids. Not dose-related.

24
Q

Cyanide antidote

A

Hydroxocobalamin (B12)

2.5g (1 ampuole) over 15 mins

25
Q

Sulfonylureas treatment

A

Adult: 50mL of 50% dextrose
Child: 5ml/kg of 10% glucose
Then glucose IVI

ANTIDOTE
Octreotide
50mcg IV bolus
Then 25mcg/hr IVI for at least 24 hours

Children = 1mcg/kg/hr

26
Q

What is cinchonism

A

Seen in quinine overdose

  • nausea, vomiting
  • vertigo
  • tinnitus
  • hearing loss

NB - quinine also causes late onset visual disturbance –> deaf AND blind!

27
Q

High Dose Insulin Therapy

A
  • used in Ca2+ or B blocker toxicity with HD compromise
    1. Glucose 25g (50mL of 50%) IV bolus
    2. short acting insulin 1U/kg IV bolus
  1. Glucose 50mL/hour via CVL - titrate to euglycaemia
    +
    short acting insulin 0.5IU/kg/hr IVI - titrate up to 1-2IU/kg/hr

Monitor for

  • hypokalaemia (target 3-3.5)
  • hypomagnesaemia
  • hypophosphataemia
28
Q

Ethanol (Antidote) dosing

A
  • Target level > 100mg/dl (22mol/l)

ORAL or NG

  • 1.8ml/kg of 43% ethanol (3x 40ml shots of vodka in 70kg adult) bolus
  • maintenance = 0.2-0.4ml/kg/hr (one shot/hr)

IV

  • loading 8mL/kg of 10% ethanol IV
  • maintenance 1-2mL/kg/hr
29
Q

Features that differentiate cocaine toxicity from other Na channel blocker toxicity?

A

Fever

Hypertension

ACEM Fellowship (10 decks)

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