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Pediatric Emergency Medicine > Toxicology > Flashcards

Toxicology Flashcards

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1
Q

What signs and symptoms would you expect to see in an ingestion of aminata phalloides/death cap mushrooms

A

Causes a delayed onset hepatotoxicity 6-10 hours later with sxs of N/V/D, abdominal pain, hematuria, proteinuria, elevated LFTs

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2
Q

What treatments should you consider if you suspect an ingestion of aminata phalloides/death cap mushrooms?

A

Activated charcoal, n-acetylcysteine (NAC), high dose penicillin vs cephalosporin

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3
Q

What signs and symptoms would you expect with an ingestion of a beta blocker?

A

N/V, bradycardia, hypotension, dysrrhythmia with qrs widening which can lead to torsades, pulmonary bronchospasm, hypoglycemia, hyperkalemia, seizures, coma

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4
Q

How should you manage a beta blocker ingestion?

A
  • Give judicious fluids b/c the decreased cardiac inotropy is a set up for fluid overload and effective CHF
  • Widened qrs=NaHCO3
  • Torsdes=magnesium
  • Arrhythmia=PALS
  • Seizures=benzos
  • acutely ingested=activated charcoal; bowel cleanout if known extended release formulation
  • antidote is glucagon!
  • Due to the potential for sxs to arise 8-12 hrs after ingestion, err on the side of admission!
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5
Q

What are examples of calcium channel blockers?

A

diltizem, amlodipine, verapamil, nifedipine

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6
Q
  • What are vital sign changes with calcium channel blocker ingestion?
  • What are physical exam findings/sxs with calcium channel blocker ingestion?
  • What are potential changes on EKG?
  • What are lab changes seen with calcium channel blocker ingestion?
A
  • Vitals-hypotension, bradycardia
  • PE/sxs-N/V, lethargy, seizure, coma
  • EKG-AV blockade, sinus arrests/junctional rhythms, tachydysrhythmia, torsades
  • Labs-hyperglycemia, metabolic acidosis
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7
Q

How should you manage calcium channel blocker ingestion?

A
  • Give judicious fluids b/c the decreased cardiac inotropy is a set up for fluid overload and effective CHF
  • seizures=benzos
  • Torsades=magnesium
  • Arrhythmia=PALS
  • acutely ingested=activated charcoal; bowel cleanout if known extended release formulation
  • Give IV calcium chloride or calcium gluconate
  • If any signs of myocardial instability give high dose insulin-1 Unit/kg of Regular Insulin prior to infusion of 1 Unit/kg/hr
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8
Q

What lab value helps to differentiate between beta blocker and calcium channel blocker ingestion?

A

Glucose!

  • Beta blocker ingestion=hypoglycemia
  • calcium channel blocker ingestion=hyperglycemia
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9
Q

What household products may contain camphor?

A

Vicks vaporub, mothballs, campho-phenique, camphorated oils

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10
Q
  • What are signs and symptoms of camphor ingestion?

- What causes death in these patients?

A
  • N/V, burning of the mouth &/or throat, ataxia, drowsiness, confusion, twitching, seizure, coma.
  • Death from CNS depression or respiratory arrest
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11
Q

What household product is ethylene glycol commonly found in?

A

antifreeze!

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12
Q

What are signs and symptoms of ethylene glycol toxicity?

What will be seen on lab work for ethylene glycol toxicity?

A
  • agitation, seizure, coma, cardiac dysrhythmias, hypotension, kussmaul breathing, respiratory depression
  • lab: elevated anion gap metabolic acidosis, calcium crystaluria
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13
Q

What is the treatment of ethylene glycol toxicity?

A
  • Early ingestion-try to competitively inhibit toxin formation by giving IV ethanol or fomepizole
  • If toxicities are arising hemodialysis is required
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14
Q

What are the signs and symptoms of lomotil ingestion?

A
  • Opioid intoxication effects-respiratory deppression, miosis, bradycardia, hypotension, paralytic ileus, coma
  • Anticholinergic effects-lethargy, agitation, flushing, dryness, paralytic ileus, mydriasis
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15
Q

How do you treat lomotil ingestion?

A

ABCs and supportive care are mainstays, consider narcan for anti-opioid effects and physostigmine for cholinergic stimulation

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16
Q

What household products contain methyl salicylates?

A

IcyHot patches, wintergree oil, muscle pain relief creams/ointments

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17
Q
  • What are symptoms of methyl salicylate ingestion?

- What can be seen on labwork?

A
  • Early on they cause respiratory alkalosis but can also see metabolic alkalosis 2/2 vomiting, metabolic acidosis, and late onset respiratory acidosis
  • Sxs include N/V, CNS edema, tinnitus, lethargy, seizures, coma, and hyperthermia
18
Q

How should you manage a methyl salicylate ingestion?

A
  • ABCs, supportive care, activated charcoal for early ingestion
  • NaHCO3 is the antidote
  • Severe cases may require hemodialysis
19
Q

What are examples of sulfonylureas and what is their mechanism of action?

A
  • glyburide, glipizide

- Oral hypoglycemic agents that act as insulin secretagogues

20
Q
  • What are signs and symptoms of sulfonylurea ingestion?

- What electrolyte abnormality would you see?

A
  • lethargy, agitation, tachycardia, seizure, confusion, diaphoresis,
  • hypokalemia
21
Q

How should you manage sulfonylurea ingestion?

A
  • ABCs, supportive care, activated charcoal early, glucose infusion as needed, benzos for seizure
  • Ocreotide can help stabilize pancreatic insulin secretion
22
Q

What conditions is theophylline commonly used to treat?

A

asthma, COPD, neonatal apnea

23
Q

How does theophylline work?

A
  • releases endogenous catecholamines to stimulate beta 1&2 receptors
  • blocks adenosine receptors of the CNS–>CNS hyperexcitation and vasoconstriction
24
Q

What are symptoms of theophylline intoxication?

A

vomiting, tremor, anxiety, tachycardia, hypokalemia, metabolic acidosis, glucose instability, ventricular dysrhythmia, hypotension, intractable seizures

25
Q

How is theophylline ingestion managed?

A
  • ABCs, supportive care, benzos for seizures
  • activated charcoal can disrupt entero-hepatic circulation
  • esmolol can parodoxically help with hypotension by normalizing over-stimulated beta receptors
  • Avoid over aggressive tx of hypokalemia as it is actually shifted intracellularly
26
Q

What are examples of TCAs?

A

amitriptyline, doxepin, amoxapine

27
Q

What are signs and symptoms of TCA ingestion?

A
  • ventricular dysrhythmia, hypotension 2/2 vasodilation

- agitation, lethargy, stupor, coma, seizure, anticholinergic sxs (flushing, dryness, mydriasis)

28
Q

How is TCA ingestion managed?

What medications should be avoided in treating a TCA ingestion?

A

ABCs, supportive care, activated charcoal early

  • NaHCO3 for widened qrs
  • seizure=benzo
  • hypertonic saline can overcome sodium channel blockade
  • Tx hypotension with epi or NE, avoid using dopamine as it can paradoxically drive BP lower
  • Avoid treating anticholinergic effects with physostigmine
29
Q

What are the antidotes to these common poisonings?

  • Iron
  • neuroleptics–>dystonic reactions
  • anticholinergics
  • Isoniazid
  • Warfarin
A
  • Iron=Deferoxamine
  • Neuroleptics (dystonic rxn)=Benztropine
  • Anticholinergics=Physostigmine
  • Isoniazid=Pyridoxine (Vitamin B6)
  • Warfarin=Vitamin K
30
Q

How should barbiturate and benzo intoxications be managed?

A
  • There is no direct antidote
  • Give activated charcoal by mouth or a tube through the nose into the stomach
  • Breathing support, including oxygen, intubation if necessary-these patients may have severe respiratory depression
  • IV fluids
  • Treat symptomatically
31
Q

What are the toxic effects of the following plants?

  • Oleander
  • Jimsonweed
  • Dumbcane
A
  • Oleander- effects similar to cardiac glycosides and digoxin toxicity.
  • Jimsonweed- anticholinergic effects-lethargy, agitation, flushing, dryness, paralytic ileus, mydriasis
  • Dumbcane- causes local (not systemic) toxicity due to the insoluble calcium oxalate crystals. Ingestion can cause severe oral pain due to mucosal irritation.
32
Q
  • What are symptoms of digitalis poisoning?
  • What electrolyte abnormalities are common?
  • How should this be treated?
A
  • asymptomatic for several hours then develop significant gastrointestinal symptoms-anorexia, nausea, vomiting, and abdominal pain; Neurologic sxs-confusion and weakness; any arrhythmia but most likely bradyarrhythmias and heart block
  • Hyper and hypokalemia are common abnormalities encountered
  • Patients who recently ingested digoxin may benefit from activated charcoal. Consult toxicology to determine if digoxin-specific antibody (Fab) fragments are warranted
33
Q
  • What are symptoms of serotonin syndrome?
  • What are drug classes that can cause this?
  • What are general management principles?
  • What is the antidote?
A
  • Signs and symptoms associated with serotonin syndrome include confusion, agitation, disorientation, tremor, vomiting, shivers, myoclonus, ataxia, hyperreflexia, mydriasis, and hyperthermia.
  • amphetamines, MAO inhibitors, SSRIs, SNRIs, tryptans, fentanyl, lithium-many more, look at a table!!!
  • Discontinue of all serotonergic agents; Supportive care aimed at normalization of vital signs; Sedation with benzodiazepines, Administration of serotonin antagonists (cyproheptadine), Assessment of the need to resume use of causative serotonergic agents after resolution of symptoms
  • Antidote if the above fails is cyproheptadine!!!
34
Q
  • What are symptoms of organophosphate poisoning?

- What is the antidote to this?

A
  • DUMBBELS: diarrhea, urinary incontinence, miosis, bradycardia, bronchospasm, emesis, lacrimation, and salivation. Also associated with muscle weakness, paralysis, and CNS effects.
  • The antidotes are atropine and pralidoxime.
35
Q
  • Describe symptoms consistent with methemoglobinemia
  • What types of drugs can cause this?
  • What is the treatment?
A
  • dizziness and cyanosis following ingestion of medication known to cause methemoglobinemia
  • Many drugs including local anesthetics, sulfonamide antibiotics, phenazopyridine, dapsone, and chloroquine can cause methemoglobinemia.
  • Methemoglobinemia usually responds to methylene blue.
36
Q

What are common cardiac manifestations of TCA overdose?

A

-hypotension. Sinus tachycardia with QRS prolongation, atrioventricular block, ventricular tachycardia, ventricular fibrillation, torsades de pointes (less common).

37
Q
  • What are symptoms associated with arsenic poisoning?

- What are mees lines?

A
  • If exposed to arsenic gas, the most common presenting symptoms are abdominal pain, hematuria, and jaundice along with diminished mental status.
  • Mees lines are white lines on the fingernails indicating chronic arsenic poisoning
38
Q
  • What are symptoms associated with hydrogen sulfide exposure?
  • What clue can be helpful to alert you to this exposure?
A
  • rotten egg smell, keratoconjuctivitis, and upper airway irritation with coughing and confusion.
  • Coins and jewelry will blacken
39
Q
  • What are the most common ingested agents leading to hospitalization in children?
  • What are the effects of clonidine exposure?
  • How should clonidine exposure be managed in the ED?
A
  • Clonidine and buprenorphine are the most common agents causing hospitalization due poisoning in children.
  • Clonidine is an α2-agonist that causes low blood pressure, bradycardia, and sedation.
  • Early management of the poisoned child should include assessment and treatment of problems with airway, breathing, and circulation, as well as early consultation with the poison control center and/or a toxicologist. Activated charcoal can be effective early in the ingestion. If required intubate prior to activated charcoal. Narcan can be used to reverse respiratory and neuro depression in clonidine ingestion
40
Q

What history points need to be taken, if possible, for any ingestion?

A
  • Time of ingestion
  • Maximal possible dose of ingestion
  • Formulation of ingestion
  • Co-ingestions
  • Patient’s medical conditions
41
Q
  • What is the dose of activated charcoal?

- When is activated charcoal of highest benefit?

A
  • Activated Charcoal (0.5 – 1 g/kg)

- Within an hour of ingestion

42
Q

-What is the dosing of calcium gluconate?

A

10% Calcium Gluconate 60 mg/kg (0.6 mL/kg)

Pediatric Emergency Medicine (18 decks)

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