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CEN Review > Toxicology Emergencies > Flashcards

Toxicology Emergencies Flashcards

1
Q

What are 10 causes of miosis?

A

-Opioids
*Central alpha 2 agonists
*Organophosphates
* Phencyclidine
* Sedative hypnotics
*Phenothiazines
*Nicotine
*Pilocarpine eye drops
*Olanzapine (Zyprexa)
*Pontine hemorrhage

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2
Q

This is rarely utilized or recommended but if used:
*Within 1-2 hrs of ingestion
* Large bore OGT
* Protect the airway, risk of aspiration
*Contraindications: Caustics, Nontoxic agents, AMS1-2 hrs

A

Gastric Lavage

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3
Q

Activated Charcoal absorbs most ingestants and prevents absorption by the gut. Should use within 2-4 hours. Do not use for what 6 things? (PHAILS)

A

P Pesticides
H Hydrocarbons
A Alcohol, acids, alkali
I Iron preparations
L Lithium
S Solvents

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4
Q

Specific Antidotes and Reversal Agents: opioids

A

naloxone

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5
Q

Specific Antidotes and Reversal Agents: cyanide

A

Cyanokit (hydroxocobalamin); Cyanide Kit (amyl nitrate) no longer available

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6
Q

Specific Antidotes and Reversal Agents: benzodiazepines

A

Flumazenil (Romazicon)

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7
Q

Specific Antidotes and Reversal Agents: heparin

A

Protamine

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8
Q

Specific Antidotes and Reversal Agents: warfarin

A

Vitamin K +/- FFP or PCC

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9
Q

Specific Antidotes and Reversal Agents: sulfonylureas

A

Octreotide (Sandostatin)

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10
Q

Specific Antidotes and Reversal Agents: heavy metals

A

chelating agents

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11
Q

Specific Antidotes and Reversal Agents: Extravasation of Vasopressors

A

Phentolamine (Regitine)

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12
Q

Toxicity produces delayed hepatic necrosis. Serum levels 140mg/kg are toxic. Signs and symptoms develop slowly:
* Phase I – GI upset -> Phase II – hepatic failure -> Phase III – multi-organ failure, DIC -> Phase IV – death or recovery

A

Acetaminophen (APAP) Poisoning

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13
Q

Used for tylenol OD
-Analogue of Glutathione
*Best within 8 hr of ingestion
* Has little benefit past 24 hr mark
* Total dose: 1330 mg/kg over 72 hours

A

N-acetylcysteine (NAC, Mucomyst)

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14
Q

Management of Tylenol overdose (4)

A

-Obtain 1st blood level 4 hrs after ingestion
*Activated charcoal if ingestion ≤ 4 hrs
*N-acetylcysteine (NAC, Mucomyst)
*Acetadote – IV formulation, total dose: 300 mg/kg over 21 hours

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15
Q

*Gastric irritant
* “Uncouples” oxidative phosphorylation – interferes with the breakdown of glucose and the formation of ATP in the Krebs cycle
*Decreases platelet function
*Inhibits vitamin K dependent clotting factors
* Peak serum levels occur 2-6 hours after acute
ingestion (6-9 hours for enteric coated)
* Toxic dose to produce symptoms is 200-300mg/kg. More than 400mg/kg is lethal

A

Salicylates

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16
Q

Salicylate Poisoning Symptoms

A

-TINNITUS
-HYPERVENTILATION
-RESPIRATORY ALKALOSIS
-METABOLIC ACIDOSIS
*Nausea/Vomiting
*Deafness
*Diaphoresis
*Mental status changes
*Noncardiogenic pulmonary edema
*Hyperthermia

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17
Q

management of salicylate poisoning (8)

A

-Obtain serum level on arrival and 6 hours after ingestion
* Charcoal if within 3 hrs of ingestion
* Dose every 2 hrs x3
* Fluid administration
* Monitor urine for hematuria
* Monitor for hypoglycemia and hypokalemia
* Urine alkalinization (3 amps in 1L D5W)
* Hemodialysis for severe ingestions or AMS

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18
Q

This is common in Children
* > 60mg/kg of elemental is usually a toxic dose
* Serum level peaks 2-4 hours after ingestion
*Important to know the kind and number of tablets

A

Iron Poisoning

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19
Q

Management of iron poisoning (6)

A
  • Labs: Serum iron, LFT’s, CBC, ABG
  • Abdominal films – will show undigested tablets
  • Gastric lavage and charcoal are not recommended
  • Whole bowel irrigation can be used if tablets seen on x-ray
  • Deferoxamine (DFO) IV/IM – binds with iron and increases renal excretion
  • Hemodialysis
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20
Q

Involuntary teeth clenching is an adverse effect of which of the following?

A. Marijuana
B. Ecstasy
C. Heroin
D. Gamma Hydroxybutyrate (GHB)

A

B. Ecstasy

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21
Q

A 22 year old man is brought to the ED by his friends who inform the nurse that they think he has overdosed on cocaine. Which symptoms of cocaine abuse would the nurse expect to detect during the assessment?

A. Lethargy and obtunded state
B. Constricted pupils
C. Hypothermia and tiredness
D. Euphoria and restlessness

A

D. Euphoria and restlessness

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22
Q

Durg class that includes: cocaine, PCP, ecstasy (MDMA), methamphetamine “ice”, caffeine, cold remedies, pseudoephedrine, diet pills, Ritalin
Work by stimulating the CNS producing a feeling of euphoria and super energy
Can be taken orally, parenterally or intranasally

A

CNS Stimulants (Sympathomimetics)

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23
Q

9 symptoms of CNS stimulant use

A

*Mood changes: euphoria, decreased fatigue, increased energy, agitation, paranoia, mania, anxiety
*Cardiac: Tachycardia, hypertension, cardiac
dysrhythmias, coronary artery spasm
* Tremors/Seizures
*Hyperthermia
*Teeth clenching
*Mydriasis
*Nausea/Vomiting
*Rhabdomyolysis
*Piloerection

24
Q

9 ways to treat CNS stimulant overdose

A
  • Activated charcoal for ingestions
  • Whole bowel irrigation for body packers
  • Benzodiazepines
  • Rehydration
  • Monitor for cardiac dysrhythmias
  • NaHCO3 for QRS prolongation
  • Nitroprusside or Nitroglycerin for hypertension
  • Cooling measures
  • Avoid Pure Beta Blockers
25
Q

-Chemically treated herbal blend of incense
* Produces euphoria by stimulating cannabinoid receptors
* Similar products: Spice, Genie, Blaze, Red X Dawn and Zoha
* Effects: tachycardia, loss of consciousness, paranoia, hallucinations, and psychotic episodes
* Management: supportive
-Will pass drug screen which is why this is popular

A

K2 - “legal THC”

26
Q

-Synthetic amphetamine – mephedrone and
methylenedioxypyrovalerone (MDPV)
* AKA Zoom 2, Aura, Ivory Wave or Vanilla Sky, White Lightning, Hurricane Charlie
* Symptoms: hallucinations, paranoia, tachycardia, hypertension, food binges, and suicidal thoughts
* Treatment same as other amphetamines: benzodiazepines

A

“Bath Salts”

27
Q
  • “Legal Ecstasy”
    *Active ingredient is mephedrone
  • Effects: euphoria, anxiety, paranoia, agitation,
    tachycardia, hypertension, delusions, and
    diaphoresis
  • Treatment is supportive * Benzodiazepines
A

“Molly’s Plant Food”

28
Q

You are caring for a patient in the ED who has ingested 2000mg of amitriptyline (Elavil). While caring for this patient you would expect
which of the following?

A. Hyperactive effect with increased excitability
B. Premature ventricular contractions on the cardiac monitor
C. Constricted pupils with slight variation in reactivity to light
D. Oliguria and increased salivation

A

B. Premature ventricular contractions on the cardiac monitor

29
Q

5 neuro symptoms of a TCA OD

A

-CNS depression
* Irritability
* Coma
* Seizures
-Tremors

30
Q

4 anticholinergic symptoms of a TCA OD

A
  • Mydriasis
  • Flushed skin
  • Dry mucus membranes
  • Urinary retention
31
Q

7 cardiac symptoms of a TCA OD

A
  • Hypotension
  • ST & T wave changes
  • Prolonged QT intervals
  • Widened QRS
  • Conduction blocks
  • Tachycardia
  • Ventricular dysrhythmias
32
Q

Anticholinergics symptoms (6 - Memory Jogger)

A

Anticholinergics –

*Blind as a bat
*Red as a beet
*Dry as a bone
*Mad as a hatter
*Hotter than hades
*Sick like a seizure

33
Q

5 ways to treat TCA OD

A

*ABC’s
* Lavage ( EARLY < 2 hrs)
*Activated charcoal
* Systemic alkalization – pH 7.50-7.55
*Correct hypotension (Fluid Boluses, norepinephrine)

34
Q

This drug class causes
*Muscarinic Effects: SLUDGEM: Salivation, lacrimation, urination, defecation, GI, expectoration/emesis, miosis
*Nicotinic Effects: Tremors, respiratory paralysis, hypertension, tachycardia, mydriasis, AMS

Treatment: Decontamination, use PPE, ABC’s, elevate HOB, atropine - 2-5 mg every 5-10 minutes, Pralidoxime (2-PAM) – 2 gm IV followed by 24 hr infusion

A

Organophosphates

35
Q

What 2 meds are used to treat organophosphates toxicity?

A

-atropine - 2-5 mg every 5-10 minutes
-Pralidoxime (2-PAM) – 2 gm IV followed by 24 hr infusion

36
Q

White powder which can be either inhaled,
ingested, or injected
*Symptoms start within 6-8 hours of exposure
*Flu-like symptoms – cough leading to pulmonary edema
*Profuse V/D (bloody diarrhea)
*Standard precautions
*Supportive therapy

A

Ricin

37
Q

*Infection begins after inhalation of spores
*Prodromal phase: lasts a few days; flu-like
symptoms including fever, dyspnea,
nonproductive cough
*Standard precautions
*Decontamination

A

Anthrax

38
Q

Onset of Botulism:
-Inhaled?
-Food-borne?
-Wound?

A

*Inhalation - onset within 72 hours
* Food-borne - 12 - 36 hours
*Wound - 4 - 18 days

39
Q

This can be inhaled, food-borne, or absorbed through a wound. Causes double or blurred
vision, difficulty speaking and/or swallowing, dry mouth, fatigue, progressive symmetric muscle weakness beginning in the trunk and descending to extremities, death from airway obstruction and respiratory paralysis

A

Botulism

40
Q

How do we handle botulism patients? (6)

A
  • Standard precautions only
    *Respiratory precautions needed if patient is suspected of having flaccid paralysis as a result of meningitis
    *Human to human transmission does not occur
    *Majority of the toxin is inactive within 2 days of
    exposure
    *Patients and clothing should be washed with
    soap and water
  • Surfaces exposed should be cleaned with a 10% bleach solution
41
Q

In botulism, does human to human transmission does occur?

When is the majority of the toxin inactive?

A

No

Within 2 days of exposure

42
Q

A 1-year-old child has ingested an unknown amount of gasoline from an open container. He is awake, alert, and crying appropriately with a respiratory rate of 40. He smells of gasoline. Because the patient has ingested a hydrocarbon, the initial assessment of this patient will be focused on his:

A. Cardiac rhythm
B. Respiratory system
C. Gastrointestinal system
D. Central Nervous system

A

B. Respiratory system

43
Q

The higher the viscosity the lower the toxicity

Toxicity Symptoms:
*Cough, choking, dyspnea, tachypnea, hemoptysis
*Nausea/Vomiting, abdominal pain, belching,
bloody diarrhea
* Tremors/Seizures
*Burns on skin
*Ataxia, hallucinations, vertigo
*Dysrhythmias

Treatment:
*Decon Skin
* Supportive
*ABC’s
*Cardiac Monitoring
*Correct metabolic acidosis

A

Petroleum Distillates Hydrocarbons

44
Q

Which of the following cardiac rhythms is most likely to develop in a patient who overdosed on beta-blockers and is now exhibiting signs of
toxicity?

A. Atrial fibrillation
B. Torsades de pointes
C. Complete heart block
D. Supraventricular tachycardia

A

C. Complete heart block

45
Q

Glucagon is used to treat beta-blocker toxicity because it:

A. Maintains the blood glucose level above 100mg/dl
B. Has positive inotropic and chronotropic effects
C. Corrects metabolic acidosis
D. Increases the depth of respirations

A

B. Has positive inotropic and chronotropic effects

46
Q

Beta blockers can be cardiotoxic. What are 8 symptoms of this?

A
  • Junctional rhythms, bradycardia, heart blocks
  • Shortness of breath
  • Dizziness
  • Hypotension
  • Metabolic acidosis
  • GI Upset
  • Hypoglycemia – Beta blockers
  • Hyperglycemia – Calcium channel blockers
47
Q

7 ways to treat beta blocker toxicity

A

-Activated charcoal
*Whole bowel irrigation
*IV Calcium
*IV glucagon (3-5 mg IV, infusion: 2-5 mg/hr; this has positive inotropic and chronotropic effects)
*Hyperinsulinemiaeuglycemia Therapy
*IV Lipid Emulsion Therapy
*Monitor Glucose & Potassium

48
Q

Most overdoses of this are acute. Can be from oral or IV preparations, plant ingestions (foxglove, oleander and lily of the valley), toad toxins (bufotoxins). Toxicity can occur close to the normal narrow therapeutic range (0.5-2 ng/ml).

Symptoms:
-Altered mental status
*Bradycardia
*Dysrhythmias (atrial in children)
*Heart blocks
*Hypotension
*Nausea and vomiting
* Yellow or green halos/hazes in field of vision

A

Digoxin Toxicity

49
Q

What is given to treat life threatening complications associated with digoxin toxicity?

A

Digibind

50
Q

The priority treatment of choice for methanol ingestion may include:

A. Ethanol PO
B. Activated charcoal PO
C. Flumazenil (Romazicon) IV
D. Naloxone (Narcan) IV

A

A. Ethanol PO

51
Q

Toxic alcohol that will kill you. Calcium oxalate crystals in urine -> renal failure, mental
status changes

Treatment:
-Sodium Bicarb Infusion to treat acidosis
* Fomepizol (Antizol)
* Ethanol 10% infusion or PO
* Folinic or Folic Acid for methanol
* Hemodialysis

A

Ethylene glycol (antifreeze)

52
Q

Toxic alcohol that will kill you. Causes mental status changes, vision changes including
blindness, GI upset.

Treatment:
-Sodium Bicarb Infusion to treat acidosis
* Fomepizol (Antizol)
* Ethanol 10% infusion or PO
* Folinic or Folic Acid for methanol
* Hemodialysis

A

Methanol (wood alcohol)

53
Q

Toxic alcohol that likely will not kill you. Causes CNS depression, dizziness, poor coordination, GI upset, gastritis, acetone breath. Treatment is supportive.

A

Isopropyl alcohol (isopropanol; rubbing alcohol)

54
Q

5 ways to treat Ethylene glycol & methanol toxicity

A
  • Sodium Bicarb Infusion to treat acidosis
  • Fomepizol (Antizol)
  • Ethanol 10% infusion or PO
  • Folinic or Folic Acid for methanol
  • Hemodialysis
55
Q

A 25-yr-old college student took 25 tablets of Dimetapp as a suicidal gesture approximately 3 hours ago. The patient presents to the ED alert and oriented x4. Initial vital signs are stable. The most effective way to manage this patient’s toxic emergency is to:

A. Give syrup of ipecac
B. Perform gastric lavage
C. Give activated charcoal
D. Give polyethylene glycol-electrolyte solution (GoLytely)

A

C. Give activated charcoal

56
Q

Activated charcoal would not be administered to a patient who had ingested which of the following substances?

A. Tricyclic antidepressants
B. Anticholinergic drugs
C. Lithium
D. Cocaine

A

C. Lithium

57
Q

An ED nursing colleague has been taking ginkgo biloba for several months to enhance thinking and sex drive. While on duty, the nurse experiences chest pain and is diagnosed with a myocardial infarction. Knowing the nurse has taken ginkgo, you as the primary nurse would be very hesitant to administer which of the following medications or treatments?

A. Lidocaine
B. Morphine sulfate
C. Heparin
D. Oxygen

A

C. Heparin

Ginkgo decreases platelets

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