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RCE > Toxicology > Flashcards

Toxicology Flashcards

1
Q

Management Dig Toxicity

A

1) NS
2) Digibind if:
- Hemodynamically significant arrhythmia
- K >5, AKI
- Altered LOC

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2
Q

Osmolar Gap Calculation

A

Serum Osm - [2Na + Gluc + BUN + 1.25*EtOH]

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3
Q

DDX High Anion Gap (>12), Normal Osmolar Gap (<=10)

A 
Methanol ingestion (late)
Uremia/AKI
DKA (and other ketoacidosis - starvation, ETOH)
Propylene glycol
Lactic acidosis - A/B
Ethylene glycol/EtOH ingestion (late)
Salicylates ingestion

Cyanide/CO poisoning
Tylenol infection

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4
Q

DDX High Anion Gap (>12) and High Osmolar Gap (>10)

A 
Methanol 
Ethylene Glycol
Propylene Glycol
EtOH (can correct for this in calc OG)
ESRD (without IHD)
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5
Q

DDX High Osmolar Gap (>10), Normal Anion Gap (<=12)

A 
Early Methanol/Ethylene Glycol/Propylene Glycol
Early EtOH
Isopropyl alcohol
Hypertriglyceridemia
Hyperproteinemia
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6
Q

Manifestations ASA toxicity

A

Early:

  • NV
  • Hyperventilation (resp alkalosis)
  • Tinnitus
  • Fever

Late:

  • AGMA
  • Arrhythmia
  • HTN –> Hypotension
  • Non-cardiogenic pulm edema
  • Cerebral edema, coma, seizure
  • AKI
  • Thrombocytopenia
  • Elevated INR (factor 2 depletion)
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7
Q

Acid-base abnormality in ASA toxicity

A 
Resp alkalosis + AGMA
If see resp acidosis: 
-CNS depression
-Acute lung injury
-Mixed overdose: benzos, EtOH
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8
Q

Treatment ASA Toxicity

A

1) Charcoal/WBI if within 2 hrs (longer if enteric coated or bezoar), NOT if somnolent.
2) Dextrose 1 amp - for neuroglycopenia

3) Sodium Bicarb infusion to alkalinize urine 1-2amps then 250cc/hr (target bld pH 7.4-7.5, urine pH 7.5-7.8)
* Correct hypoK first

4) IHD indications:
- Worsening vitals, hypoxemia, aLOC despite tx
- Severe acidemia pH <=7.20 despite tx
- Vol overload preventing Na bicarb
- ASA lvl >7.2mmol/L w normal renal fcn or >6.5 with AKI
- Hepatic failure with coagulopathy

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9
Q

Indication and C/I to methylene blue

A

Indications:
- Symptoms or methemoglobinemia >20%

C/I:

  • On SSRI/SNRI/MAOi or other serotonergic agent (causes serotonin tox)
  • G6PD deficiency
  • Pregnancy
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10
Q

Manifestations of TCA Overdose & Ix

-what causes false positive

A 
Arrhythmias: Wide QRS, long QT, Sinus tach, VT, ECG (tall R in aVR, deep S in 1/avL, Type 1 Brugada - RBBB downslope STD V1-V3)
Altered LOC, agitation, psychosis
Seizures (if QRS>100)
Hypotension 
Anticholinergic toxidrome

Ix: ECG, VBG shows resp acidosis
TCA serum lvls not helpful
Urine false + for TCA w/ QTP, benadryl, cyclobenzaprine

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11
Q

Treatment TCA overdose

A

1) Charcoal or WBI if within 2 hrs
2) Seizures: Benzos –> propofol (NO dilantin bc cardiac tox)

3) Arrhythmia:
- QRS>100, VT, hypotension: Sodium bicarb (bolus–> maintenance) targetting pH 7.5-7.55, QRS <100
- Refractory VT: MgSO4 –> Lido –> Intralipid –> ECMO

  • No increased elimination or antidote
  • Avoid flumazenil if co-ingestion bc lowers sz threshold
  • NO physostigmine - causes cardiac arrest in TCA tox
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12
Q

Clues to determine which toxic EtOH

A

1) Ethylene glycol
- CN palsies
- Urine + oxalate crystals –> hematuria, dysuria, flank pain
- HypoCa –> prolonged QT

2) Methanol:
- Blindness, retinal sheen, RAPD, optic disk hyperemia
- Mydriasis

3) Isopropyl
- High OG, Low AG

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13
Q

Treatment Toxic EtOH

A

Isopropyl –> Supportive

Methanol/Ethylene Glycol:

1) Fomepizole/EtOH if:
- known ingestion and OG >10 (if already low, too late)
- possible ingestion and 2 of: pH <7.3, bicarb <20, OG >10, urine + oxalate crystals
- Serum MeOH >6.2, EG >3.2

2) Na Bicarb, target pH >7.35

3) IHD if:
- High or persistent AGMA
- End organ dmg (AKI, vision, coma, seizure)
- pH<=7.15
- Very high lvl parent alcohol

*no role of decontaminating (NG if w/i 1h)

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14
Q

Serotonin Syndrome Features

A 
HYPERREFLEXIA, MYOCLONUS
Fever
Diaphoresis
Autonomic instability (HTN, tachycardic)
ALOC - anxiety, agitated

Onset within24h, offset 24h

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15
Q

Triggers serotonin syndrome

A 
SSRIs, SNRIs, TCA, MAOis
Fentanyl, Tramadol 
Serotonin Ag: Triptans, Ergot
VPA, St John's wort 
Cocaine, MDMA
Methylene Blue
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16
Q

NMS Features

A

FARM
F: Fever
A: Autonomic instability (LABILE BP, dysrhythmia, diaphoresis)
R: Rigidity and HYPOREFLEXIA (NO CLONUS)
M: Mental status change (agitation, catatonia, coma)

Onset days to weeks, offset 2 weeks

17
Q

Triggers NMS

A

Anti-psychotics (Typicals >Atypicals)

Anti-emetics (domperidone, metoclopramide, prochlorperazine)

18
Q

Treatment Serotonin Syndrome

A

Stop agent
Supportive care
Benzos (target no agitation or hypertonia)
Cryptoheptadine if refractory

19
Q

Treatment NMS

A

Stop agent
Supportive care
Benzos
Dantrolene/Bromocriptine as adjuncts

20
Q

Anticholinergic Toxidrome

A 
Fever
Hypertensive
Tachycardic 
Red + Dry
Dilated pupils 
Confused/Agitated
Tremor 
Absent Bowel sounds, urinary/fecal retention
21
Q

Sympathomimetic Toxidrome

A 
Increased fever, BP, HR, RR
Red + sweaty 
Dilated pupils
Altered LOC
\++ Bowel sounds
22
Q

Cholinergic Toxidrome

A

Sweaty, salivation, lacrimation, urinary/fecal incontinence
Pupils constricted
Bronchorrhea/tachypnea
+/-Low HR/BP

23
Q

Narcotic Overdose Presentation

A 
Dry
Hypothermic
Pinpoint pupils
Low HR/BP
Very low RR 
Coma/Stupor
24
Q

Treatment organophosphate toxicity

A
  • Atropine if: miosis, sweating, hypotension, resp distress, bradycardia
  • 100% FiO2 +/- ETT **avoid succinylcholine (cleared by AchE), can use Roc at high dose
  • IVF for hypotension and brady
  • Wash patient thoroughly, wear protection

*atropine S/E: agitation, urinary retention, ileus, hyperthermia, tachy causing MI

25
Q

Treatment BB/CCB OD

A

Glucagon

High dose insulin with dextrose

26
Q

Carbon Monoxide Poisoning: Diagnosis

A

CarboxyHb >3% in non-smokers
>10-15% in smokers
PaO2 normal bc it reflects dissolved O2
Pulse Ox cannot screen for CO

27
Q

Carbon Monoxide Poisoning: Treatment

A

1) High flow O2 by NRB (100%)
2) Remove source of CO
3) Hyperbaric O2 indications:
- COHb >25% (>20% if pregnant, or fetal distress)
- pH <7.1
- Coma
- MI
- Within 6h of exposure

*if CO poisoning after smoke inhalation, must tx for cyanide poisoning

28
Q

Cyanide Poisoning: Treatment

A
  • 100% O2 via ETT
  • Hydroxycobolamine 70 mg/kg (aka Cyanokit)

2nd line. If antidote unavail, use amyl/Na nitrites + Na thiosulfate (S/E hyperNa)
Target methemoglobin concentration 20-30%

Dialysis should NOT be done

29
Q

Metformin overdose Tx

A

1) Na Bicarb
2) Supportive Care
3) IHD if:
- Lactate >= 20
- pH <= 7
- Shock requiring vasopressors
- Profoundly depressed LOC
- Liver failure with INR >= 1.5
- Failure of supportive care after 2-4 hrs

30
Q

ECG prolonged QT causes

A
  • Anti’s: -biotic, -psychotic - emetic - depressants - arrhythmics
  • Lytes: Hypo-
  • Cocaine
31
Q

Dig toxicity ECG

A
  • Tachy (VT/VF) or brady (2nd-3rd HB)
  • Accelerated junctional tachy
  • Do NOT give Ca for HyperK
32
Q

Pupil changes with toxins

A

Dilated: anticholinergic, cocaine, MDMA, hallucinogen, methanol, withdrawal from opioid

Normal: hypothermia, barbituates, antipsychotics

Constricted: cholinergic, opioid

33
Q

S/S Carbon Monoxide vs Cyanide poisoning

A

CO:

  • Cherry red lips/skin
  • H/A, ALOC, nausea

Cyanide (smoke inhalation or nitroprusside)

  • Smells of bitter almonds
  • Cherry red skin
  • Equalization of arterial and venous O2 sat
  • ALOC
  • LACTATE>8
  • Metabolic/Lactic acidosis with increased AG –> CV collapse and death
34
Q

Cyanide poisoning Dx

A

Cyanide level >2.4 (resp depression/coma), >3 = death
Venous O2 sat from SVC or PA cath >90% (ie decreased utilization) - also in CO or hydrogen sulfide
ECG: nonspecific: blocks, bady, tachy

35
Q

Lithium overdose S/S

A

GI: N/V/D
CV: T wave flattening in precordial leads, QT prolong, brady, Brugada unmasked
Heme: Leukocytosis
CNS: dizzy, lightheaded, orthostatic, lethargic, slurred speech, ataxia, tremor, myoclonus

36
Q

Lithium overdose Tx

A

NO ROLE FOR BICARB

Whole bowel irrigation if within 6h ingestion, unknown amount, sustained release, symptoms, or increasing levels (no role for charcoal)

IVF
DO NOT force diurese (increases retention)

IHD if:

  • Arrhythmias
  • Seizures or severe ALOC
  • Li lvls >5mmol/ or >4mmol/L with AKI (Cr>176)
37
Q

Organophosphate poisoning S/S

A

AchE inhibitor –> excess Ach
CVS: QT prolong, IM, CV collapse
Resp: resp failure (CNS depression), diaphragmatic weakness, secretions, bronchoconstriction
Neuro: lethargy, sz, coma; intermed syndrome (24-96h after exposure: neck flexion, hyporeflex, CN abN, prox muscle weaknes); delayed neuropathy (1-3wks post ingestion painful stocking/glove paresthesia then motor polyneuropathy w/ flaccid weakness of lower extremities)

RCE (18 decks)

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