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PEM Boards > Toxicology > Flashcards

Toxicology Flashcards

1
Q

6-month-old previously healthy boy is brought to the emergency department after the parents noted a bluish hue to the child’s digits. Sat 84% on RA.. Mom applied benzocaine for teething this weekend. What is the toxidrome? What is the antidote?

A

Methemoglobinemia. Converts Fe2+ to Fe3+ which has a strong affinity to oxygen and cannot release to tissue. Causes blood to appear “chocolate brown.” Sat-Arterial gas split (no change in dissolved oxygen value). Tx w/ removal of the agent, methylene blue. Indications for methylene blue: Methemoglobin concentration >30%, poor end-organ perfusion (unstable vital signs, ischemic chest pain, elevated lactate, or changes in mental status). CANNOT ADMINISTER TO PERSON WITH G6PD Deficiency.

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2
Q

Fe Toxicity Antidote

A

Deferoxamine. Indications for chelation: Fe levels >500 mcg/dL, intractable emesis, lethargy, metabolic acidosis, signs of shock)

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3
Q

Opiate Toxicity Antidote

A

Naloxone

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4
Q

Cyanide Toxicity Antidote

A

Consider if Lactate >10, Hydroxycobalamin, Cyanide kit

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5
Q

CO antidote

A

100% Oxygen
Hyperbaric oxygen if end organ damage, CO level greater than 25%, or if pregnant and CO level greater than 15%

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6
Q

Methadone half life

A

55 hours in opiate naive patients, 24 hours in opiate tolerant patients

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7
Q

Tylenol toxic dose

A

Large therapeutic index - minimum dose for toxic effects is 150 mg/kg. Remember kids <8 may tolerate higher doses 200-250 mg/kg

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8
Q

Organophosphate antidote

A

Atropine, Pralidoxime for long term therapy to prevent aging of the organophosphate.
Decon requires that health workers use neoprene gloves (organophosphates penetrate latex) and charcoal cartridge masks

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9
Q

Anticholinergic antidote

A

Physostigmine

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10
Q

TCA overdose

A

Bicarb

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11
Q

Drugs that CANNOT be eliminated w/ activated charcoal

A

Metals (ie things on the periodic table ex. lithium, fe, pb –> in these cases consider whole bowel irrigation with PEG), Liquids (ie toxic alcohols)

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12
Q

Toxic Alcohol that DOES NOT cause a metabolic acidosis

A

Isopropyl Alcohol (IN CONTRAST, remember MUDPILES - methanol, uremia, dka, paraldehyde, isoniazad, lactic acidosis, ethanol and ethylene glycol, salicylate)

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13
Q

Signs of Fe Overdsose

A

1) Early: GI distress occurs within 6 hours 2) mitochondrial damage causes lactic acidosis 3) may ultimately cause liver failure

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14
Q

Serotonin Syndrome v. NMS: Hours of onset

A

SS occurs within hours, NMS can occurs days to weeks after exposure

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15
Q

Signs and symptoms of NMS v. SS

A

Same: Autonomic instability, neuromuscular dysfunction, hyperthermia. SS: Myoclonus, hyperreflexia. NMS: Lead pipe rigidity, bradykinesia

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16
Q

Serotonin Syndrome Treatment

A

1) Sig supportive care 2) Benzodiazepine 3) Cyprohepatdine (anticholinergic, can help, use later in the course)

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17
Q

NMS Treatment

A

1) Supportive care 2) Can consider dantrolene

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18
Q

Malignant Hyperthermia treatment

A

1) Dantrolene (skeletal muscle relaxant)

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19
Q

Lidocaine, Bupivicaine Reversal

A

Intralipids

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20
Q

Burn toxicity considerations. What are the two toxidromes to consider? If both are simultaneously present, how should treatment proceed?

A

CO and Cyanide Poisoning. The nitrite components of the cyanide antidote kits should not be used because the CO and N can interact to create a worse lactic acidosis. Consider hyperbaric chamber if both of these conditions are present.

21
Q

Oil of Wintergreen

A

Causes salicylate toxicity. Suspect in Bengay, used for flavoring in baked goods and candies. Occassionally used as a homeopathic pain treatment.

22
Q

Salicylate Toxicity Metabolic Derangements

A

Metabolic acidosis, compensatory respiratory alkalosis. Of note, if intubating patients important to facilitate resp alk (RR >20, Tv 10-12 ml/kg).

23
Q

Alcohol levels expected: 1) Normal social drinking 2) Can cause hypotension in children 3) Can suggest impending resp collapse 4) normal rate of hourly metabolism

A

1) Normal social drinking - 100 mg/dL 2) Can cause hypotension in children - >300 mg/dL 3) Can suggest impending resp collapse - >400 mg/dL 4) normal rate of hourly metabolism - 20-30 mg/dL

24
Q

Sulfonylurea Antidote (glyburide, glypizide)

A

Function by promoting insulin release, antidote is octreotide which is 100% effective in decreasing insulin release

25
Q

HF burns

A

Add a slurry of calcium carbonate

26
Q

amantia phalloides

A

white mushroom that can kill. classically: stage I: 6-24hrs of no sxs II: V/D 12-24hrs (remember toxic mushrooms will frequently have delayed symptoms) III: seeming recovery IV: 2-4d later with liver and renal failure

27
Q

methanol v. ethylene glycol poisoning symptoms

A

ethylene glycol: results in oxalic crystals in the urine and hurts the kidneys methanol: results in formic acid and causes blindness

28
Q

Symptoms from the seeds of this flower.

A

The morning glory flower d/n cause a toxidrome. Seeds cause a toxidrome similar to LSD: hallucinations, mydriasis, perspiration, bronchorrhea, salivation, hyper or hypothermia, diarrhea

29
Q

Jimsonweed Poisoning Toxidrome

A

Anticholinergic poisoning (also from diphenhydramine, scopolamine)

30
Q

Indications for Physostigmine

A

Physostigmine indicated for severe or life-threatening ingestions of anticholinergics.

Mechanism: Short-acting reversible cholinesterase inhibitor, can be used for the management of severe anticholinergic syndrome (delirium, tachycardia, urinary retention).

Relative contraindications: asthma, cardiac conduction defects such as AV block, and parkinsonism syndrome.

Side Effects: Bradycardia, heart block

31
Q

In an organophosphate ingestion, for which symptoms should you administer atropine, and for which symptoms should you administer pralidoxime?

A

If wet (bronchorrhea, diaphoresis, siallorhea) give atropine (helps to dry secretions). If dry (fasciculations, weakness, paralysis) give pralodoxime which helps to protect the nicotinic skeletal muscle receptors.

32
Q

A 7 year old comes to the ED with a neck that is tensly abducted to the right and an inability to straighten his gaze. He was treated in a local clinic 2d ago for emesis and diarrhea. What is the best treatment?

A

Diphenhydramine

Benztropine (cogentin)

33
Q

Treatment for severe hypertension, tachycardia from cocaine toxicity.

A

Short acting beta blocker (esmolol) and vasodilator ie nitroglycerine, nitroprusside, hydralazine, or phentolamine.

34
Q

When should you draw an Fe level?

A

4-6 horus post ingestion.

35
Q

What is the best interval to administer NAC within?

A

Most effective if given within 8 hours, but should administer later in the course. Still has efficacy, just not as much.

36
Q

Dantrolene mechanism + 2 clinical scenarios that it would be useful

A

Blocks the release of calcium from the sarcoplasmic reticulum. NMS and Malignant Hyperthermia.

37
Q

How can you distinguish calcium channel toxicity from beta blocker toxicity.

A

Hyperglycemia may be present in pts who take CCBs. CCBs decrease pancreatic Ca+ release, decreasing insulin release –> hyperglycemia. May need large insulin infusion (1 U/kg/hr - yes 10x dka dose). This will improve myocardial function rapidly. Administer Ca+ Cl, likely repeatedly.

38
Q

A 4 year old has a generalized seizure after taking a medication his recently immigrated mother has for a spot on her lungs. What is the antidote? What is the metabolic disturbance that you will see with this toxidrome?

A

Isoniazad toxicity: AG metabolic acidosis, seizures. Antidote: Pyridoxine (administer in a dose equivelant to the ingested amount).

39
Q

Methemoglobinemia

A

Mechanism: Represents hemoglobin w/ Fe in oxidized state - Fe3+. Requires methylene blue to facilitate back to normal Fe2+. Chocolate brown blood.

40
Q

A 3 year old has nausea, vomitting, and hyperkalemia after spending the afternoon in grandpa’s garden. He thinks she might have ingested this flower.

A

Digoxin-like overdose picture causes nausea, emesis, bradycardia (increased AV tone), hyperkalemia. Plant sources include oleander, foxglove, lily of the valley, dogbane, red squill. Also by the cane toad.

41
Q

Bradycardia causing medication toxidromes. Name 5 classes.

A
  1. Calcium channel blockers
  2. Beta blockers
  3. Digitoxin
  4. Cholinergics
  5. Alpha-2 agonists (Clonidine)
42
Q

A 17 year old presents w/ acute cocaine toxicity and is febrile to 41, HR 150, BP 170/100. How do you treat?

A
  1. Benzo
  2. More Benzo
  3. Active cooling measures (ice packs, sprays)
  4. Second line includes phentolamine, nitroprusside drips
  5. Can use nitro tabs for MI associated w/ cocaine overdose
43
Q

Stone fruit pits (cherry, apricot, plum)

A

Contain small amounts of cyanide. Likely not clinically significant.

44
Q

Cyanokit (Hydroxycobalamin) Practical Considerations

A

Medication is bright red skin redness may stay up to 2 weeks. Medication is photosensitive. Facilates urinary excretion. cilUrine will be red. Can cause interference w/ lab tests. Compatibile w/ pregnancy and children. .

45
Q

Urinary Alkinization

What is the dose?

How is it administered?

Should you add K to the fluids?

A

Sodium Bicarb administed in salicylate poisoning (phenobarbital, methotrexate). Urinary alkinization charges the toxins and decreases reabsorption.

Administed with bolus 1-2 meq/Kg bolus then infusion of 1-1.5x maintenance rate. Need to give infusion in D5 and additional K.

46
Q

Clinical Manifestations of Hydrocarbon Exposure

A
  • Primarily aspiration. Can ultimately cause pneumonitis (as late as 48h), pneumatocoeles (as late as 10 days), pneumothoraces, necrotizing pneumonia (usually within 72h)
  • Can predispose to malignant ventricular arrythmias, sensitizes the myocardium to catecholamines. Consider avoding epi in favor of lidocaine, amiodarone.
  • Reccomendations include observation x 6-8 hours. Obtain CXR, usually when pts arrive and prior to discharge.
47
Q
A

Castor Oil Plant.
Ricin.
Acute lung injury 3-12 hours following.
Death from lung injury

48
Q

Glipizide Antidote

A

Octreotide. Can give it SC.

PEM Boards (5 decks)

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