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Emergency Med Exam 1 > Toxicology Emergencies > Flashcards

Toxicology Emergencies Flashcards

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1
Q

What is addiction?

A

Compulsive engagement in rewarding stimuli despite adverse consequences

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2
Q

What is tolerance?

A

Diminished response to drug secondary to repeat use

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3
Q

What is dependence?

A

Adapted physiologic state d/t recurrent exposure to substance (results in withdrawal if ceased)

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4
Q

What does “sola dosis facit venenum” mean?

A

The dose makes the poison
-Paracelsus
Adage indicating basic principle of toxicology

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5
Q

Which drugs are opiates?

A

Heroin, Codeine, Hydrocodone (Vicodin, Norco), Oxycodone (Percocet, Oxycontin), Morphine, Hydromorphone (Dilaudid), Fentanyl, Duragesic, Methadone

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6
Q

What is heroin derived from?

A

Opium poppy

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7
Q

Common street names of heroin?

A

H, smack, boy, horse, brown, black, tar

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8
Q

Pathophys of heroin?

A

Introduced to blood stream –> converted to morphine by enzymes –> binds to opiate R’s in reward pathway –> stimulates dopamine release & pain pathway

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9
Q

Onset of heroin?

A

Seconds to minutes

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10
Q

Duration of heroin?

A

2-6 hrs

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11
Q

Heroin methods of use?

A

Injection, smoking, snorting

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12
Q

Effects of heroin?

A

Acute CNS & respiratory depression, constricted ‘pinpoint’ pupils, nausea

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13
Q

Treatment of heroin overdose?

A

-Acute OD: Narcan
-Observation to make sure long acting narcotic not involved
-Abscesses may need drainage
-Consider endocarditis

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14
Q

What is naloxone (narcan)?

A

Competitive opioid antagonist, blocking all opioid receptors

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15
Q

ROA of naloxone?

A

IV, IM, SC, endotracheal

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16
Q

Usual starting dose of naloxone?

A

0.4mg
(repeat doses of 0.4 mg/hr may be necessary)

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17
Q

Duration of naloxone?

A

30-60 min

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18
Q

What may narcan induce?

A

Vomiting and agitation

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19
Q

What is speedballing?

A

Simultaneous IV injection of heroin and cocaine

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20
Q

Common prescription opiates of abuse?

A

Vicodin (Hydrocodone), Percocet (Oxycodone), Fentanyl

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21
Q

Signs someone is abusing prescription meds?

A

May request pure forms or report allergy to tylenol/NSAIDs

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22
Q

Who may have non-intentional OD’s secondary to uncontrolled pain or poor liver/renal function?

A

All patients but especially elderly

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23
Q

Prescription opiate OD is ________ in onset and lasts _________

A

slower in onset and lasts longer

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24
Q

S/Sx of opiate withdrawal?

A

Mildly increasing temp, yawning, rhinorrhea, lacrimation, midriasis, vomiting, diarrhea, stomach cramps, myalgia, arthralgia, irritability

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25
Q

Treatment for opiate withdrawal?

A

-Clonidine (Catapres) 0.1-0.2mg PO or transderm patch x1wk prn
*hold for SBP <150
-Dicyclomine (Bentyl) 20mg q6hr prn cramps
-Loperomide (Imodium) 2mg q6hr prn diarrhea
-Hydroxyzine HCl (Atarax) 50mg q6hr prn anxiety/sleep
-Ibuprofen 600mg q6hrs prn pain
-Methadone program may be needed for long tx

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26
Q

Cocaine is a naturally derived CNS stimulant extracted/refined from what?

A

Coca plant

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27
Q

Common street names of cocaine?

A

Crack, freebase, coke, blow, rock, crank

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28
Q

Pathophys of cocaine?

A

Binds w/ Na+ channel –> inhibits Na+ conduction/blocks ion conduction w/in myocardial and nerve cells
Inhibits monoamine reuptake –> enhanced action of NE, Epi, Dopamine

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29
Q

Onset of cocaine?

A

seconds to min

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30
Q

Duration of cocaine?

A

20-40 min

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31
Q

Cocaine methods of use?

A

Snorting MC, PO, intranasal, IV, smoking

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32
Q

Effects of cocaine?

A

Euphoria, paranoia, inc. sexual stim, inc. energy, HTN, tachycardia, coronary artery vasospasm, ruptured AAA, cerebral bleed/infarct, pneumomediastinum, pneumothorax, pneumopericardium, bullous emphysema, pulm edema, bronchospasm, alveolar hemorrhage, pneumonitis, bronciolitis, pulm HTN

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33
Q

EKG of someone who is using cocaine may show what?

A

Prolonged QRS, QT & QTc intervals, STEMI, Vtach/Vfib

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34
Q

Treatment for cocaine overdose?

A

-Benzodiazepines (Lorazepam- Ativan) 1-3mg IV prn
-IV fluids replace volume loss or if rhabdo
-BP management: Nitroprusside, Nitroglycerin, Phentolamine (AVOID BB d/t unopposed a-adrenergic activity)
-Long term tx w/ support networks/therapy

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35
Q

Can you reverse cocaine with narcan?

A

No, cannot reverse like opioids

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36
Q

Is there are true withdrawal with cocaine?

A

No, more of a hangover (requires rest/time)

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37
Q

What is synthetic marijuana marked as OTC?

A

Incense, potpourri

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38
Q

Common street names of synthetic marijuana?

A

Spice, K2, fake weed, Yucatan Fire, Skunk, Moon rocks

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39
Q

Pathophys of synthetic marijuana?

A

Synthesized compounds bind more strongly to THC R’s than regular marijuana –> more powerful, unpredictable, dangerous effect

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40
Q

Onset of synthetic marijuana?

A

15-30 min

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41
Q

Duration of synthetic marijuana?

A

2-6 hrs

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42
Q

Effects of synthetic marijuana?

A

Severe agitation/anxiety, fast/racing heart, high BP, N/V, intense hallucinations/psychotic episodes, suicidal/harmful thoughts and actions, linked to development of pneumonia

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43
Q

Treatment for synthetic marijuana?

A

Benzodiazepines (Ativan), may need large doses, wait it out

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44
Q

What are bath salts derived from?

A

Khat plant

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45
Q

What are bath salts marketed as?

A

“bath salts”, plant fertilizer, insect repellent, pond cleaners, vacuum fresheners

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46
Q

Street names for bath salts?

A

Vanilla sky, Cloud nine, Ivory wave, Aura, Blizzard, Scarface

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47
Q

Pathophys of bath salts?

A

Active chemical acts on monamine NTs as dopamine-NE reuptake inibitors –> inc. in serotonin (& to lesser extent - Dopamine)

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48
Q

Bath salts methods of use?

A

Snorted MC, ingestion, injecting, smoking, rectal

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49
Q

Onset of bath salts?

A

30-90 min

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50
Q

Duration of bath salts?

A

2-4 hrs

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51
Q

Effects of bath salts?

A

Excited delirium, tachycardia, HTN, CP, paranoia, hallucinations, panic attacks, extreme agitation, rhabdo/renal failure

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52
Q

Bath salts are not detected by what?

A

DAU-8

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53
Q

Treatment for bath salt use?

A

Benzodiazepines (Ativan), may require larger dosing, wait it out

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54
Q

What are amphetamines?

A

Pharmaceuticals originally used as OTC bronchodilator, later for narcolepsy, Parkinsons, depression, weight loss (and used by soldiers, truck drivers, students, athletes)
Today used most for ADHD/ADD (Adderall)

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55
Q

Street names for amphetamines?

A

Crystal meth, speed, crank, ice, glass

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56
Q

Pathophys of amphetamines?

A

Stimulate release of dopamine and serotonin –> dopamine stores depleted resulting in depression/need for re-use
*long term use destroys dopamine & serotonin brain cells

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57
Q

Amphetamines methods of use?

A

IV, smoking, snorting, pill abuse (Adderall)

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58
Q

Onset of amphetamines?

A

quick high that lasts 5-30 min

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59
Q

Duration of amphetamines?

A

6-12 hrs

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60
Q

Effects of amphetamines?

A

Euphoria, inc. activity, inc BP/RR, hyperthermia, insomnia, unpredictable behavior, N/V, cracked teeth, sores, skin infections, seizures, sudden death

Long term: Parkinson’s, Alzheimers-like sx, paranoia, CVA

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61
Q

Treatment for amphetamines?

A

-Haloperidol (Haldol) 5-10mg IM for agitation
-Lorazepam (Ativan) 1-4mg IM/IV for agitation or seizure
-Labetalol 20mg IV for HTN/tachycardia q10min prn

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62
Q

What did CNS depressants have early use in?

A

Medical anesthetics, ETOH, withdrawal, narcolepsy

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63
Q

Common names for CNS depressants?

A

GHB, Rohypnol, rophie, G, liquid ecstasy, “date rape drug”

64
Q

Pathophys of CNS depressants?

A

Impairs dopaminergic transmission (mech poorly understood)

65
Q

Methods of use for CNS depressants?

A

Mostly PO

66
Q

Onset of CNS depressants?

A

15-30 min

67
Q

Duration of CNS depressants?

A

90 min (peak), 2-12 hrs

68
Q

Effects of CNS depressants?

A

Euphoria, dec. inhibition, sleepiness/lethargy, muscle relaxation, disorientation, confusion, loss of balance, headache, N/V, hallucinations, seizures, amnesia, resp. depression

69
Q

Tx for CNS depressants?

A

ABCDE’s (airway, breathing, circulation, disability, exposure)
-Any signs or hx of rape: SNAKE kit & police
-Supportive usually all that is needed until wears off
-SEVERE overdose: Physostigmine 1-2mg IV over 5min (rpt in 10-15 min prn)

70
Q

How is activated charcoal made?

A

Wood heated to high temp and oxidized using acid and steam to make find particles (almost pure carbon) –> structure has huge surface area (50g = 10 football fields)

71
Q

Charcoal acts as a sponge to absorb what?

A

Chemicals/meds not yet absorbed by GI tract/into circulation

72
Q

What is charcoal usually given with?

A

Sorbitol (acts as laxative)

73
Q

What is charcoal not useful for?

A

Corrosives/solvents, iron salts, lithium, boric acid, arsenic, ethanol

74
Q

Charcoal is most effective if given in what time frame?

A

30-60min of ingestion (min use w/in 3hr)

75
Q

When is gastric lavage most effective?

A

W/in 20-60 min of ingestion
*not commonly used

76
Q

Indications for gastric lavage?

A

Removal of toxins, massive OD, highly toxic ingestions

77
Q

What does gastric lavage do?

A

Dilutes/removes corrosive liquids & empty stomach in prep for EGD

78
Q

What is whole bowel irrigation?

A

PEG lyte at high flow rates (2L/hr) to force intestinal contents out by sheer volume until rectal effluent is clear

79
Q

Indications for whole bowel irrigation?

A

Large ingestion of Fe, Li, other drugs poorly absorbed by charcoal, SR or EC tablets of valproic acid, theophylline, ASA, verapamil, diltiazem, or other dangerous drugs, FB or drug filled packets

80
Q

C/I for full bowel irrigation?

A

Ileus or intestinal obstruction, obtunded, comatose, convulsing

81
Q

Drugs that are recognized by DAU-8 (drugs of abuse urine)?

A

Amphetamines, Barbituates, Benzos, Cannabinoids, Cocaine, Methadone, Opiates/heroin, Propoxyphene

82
Q

First detection/duration of amphetamines?

A

First: 4-6hr
Duration: 1-2d

83
Q

First detection/duration of Barbituates?

A

First: 2-4hr
Duration: 1-3d

84
Q

First detection/duration of Benzos?

A

First: 2-7hr
Duration: up to 21d

85
Q

First detection/duration of Cannabinoids?

A

First: 1-3hr
Duration: up to 60d

86
Q

First detection/duration of Cocaine?

A

First: 2-6hr
Duration: 1-3d

87
Q

First detection/duration of Methadone?

A

First: 3-8hr
Duration: 1-3d

88
Q

First detection/duration of Opiates/heroin?

A

First (opiate): 1-3hr
First (heroin): 2-6hr
Duration: 1-3d

89
Q

First detection/duration of Propoxyphene?

A

First: 3-8hr
Duration: 1-3d

90
Q

MC hospitalization for overdose is due to which drug?

A

APAP (acetaminophen)

91
Q

MC cause of acute liver failure in US?

A

APAP (acetaminophen)

92
Q

Survival rate for APAP OD?

A

100% if tx w/in 8hr

93
Q

Consider accidental OD of APAP when?

A

if pt has significant pain and is attempting to self medicate

94
Q

Pathophys of acetaminophen (Tylenol)?

A

Release of cytokines, nitrogen, oxygen radicals during metabolism initiates secondary inflammation response w/in hepatic parenchyma –> fulminant liver failure, often irreversible, clotting and renal dysfunction possible

95
Q

Onset of Tylenol OD?

A

completely abs in 2 hrs, serum conc. peak w/in 4hr
Liver injury: 8-12hrs
Hepatic necrosis/failure: 3-5d

96
Q

Sx of Tylenol OD?

A

Asx initial, then N/V, anorexia, RUQ pain, jaundice, encephalopathy/coma

97
Q

Toxic dose of Tylenol?

A

Adults: 7.5-10g
Kids (1-6): 200mg/kg

98
Q

Work-up for tylenol OD?

A

-4hr APAP level from time of most recent ingestion, severity of elevations related to dose
-elevated AST (w/in 24hr)
-elevated ALT, bili, PT, lactate, phosphate, Cr (w/in 24-72hr)
-elevated ammonia (w/in 72-96hr if not tx)
-if intentional eval for coingestants w/ DAU-8

99
Q

Tx for tylenol OD?

A

Activated charcoal 1g/kg (or 50g) w/in 4hr
-N-acetylcysteine (NAC) if level meets/exceeds lower line: PO 140mg/kg or IV 150mg/kg then x2d

100
Q

Indications for immediate NAC administration w/ tylenol OD?

A

> 8hr since ingestion, pregnancy, presenting w/ hepatic failure

101
Q

Other substances of potential source for Salicylate (ASA) OD?

A

Bismuth subsalicylate (Pepto), Alza-seltzer, Aspercreme, Percodan

102
Q

Pathophys of ASA OD?

A

Inc respiratory center sensitivity, damage hepatocytes, inhibits PLT organization/amino acid synthesis

103
Q

Onset of ASA OD?

A

Variable (dosage, route)

104
Q

Effects of ASA OD?

A

Tinnitus/hearing loss, N/V, fever, lethargy, diaphoresis, epigastric pain, agitation, dec awareness, seizures or coma

105
Q

What is Reyes Syndrome?

A

Hepatic failure w/ encephalopathy
*assoc w/ tx of peds viral illness w/ ASA
*30% mortality

106
Q

Work-up for Salicylate (ASA) OD?

A

-Salicylate levels q4hrs after ingestion then q3hrs until levels decline
-ABG (metabolic acidosis)
-CBC, CMP, US, DAU-8, acetaminophen level, ETOH

107
Q

Tx for Salicylate (ASA) OD?

A

Activated charcoal 50g adults, 1g/kg kids

-Urinary alkalization to pH 7.5-8 (prevent renal diffusion reuptake): mix 5% dextrose in water D5W plus 3 ampules of sodium bicarb
*infuse at rate for urine output 2-3mL/kg/hr
*complications: hypokalemia, hypocalcemia

-dialysis if severe toxicity

108
Q

Prognosis of ASA OD?

A

Depends on serum level 6hr post ingestion
<35mg/L: no sx
35-70: moderate sx
70-100: severe
>120: potentially fatal

109
Q

Most common meds with anticholinergic activity?

A

-Tricyclics (amitripyline/Elavil, imipramine/Tofranil, Paxil, Pamelor)
-Antihistamines (Benadryl, Atarax)
-Antispasmodics (ditropan, bentyl)
-Antiparkinsons (Cogentin)
-Antiemetics (Compazine, Phenergan)
-Antipsychots (Zyprexa, Seroquel, Clozaril)
-Muscle Relaxers (Soma, Flexeril, Robaxin)

110
Q

Who accounts for half of all exposures of anticholinergic OD?

A

Children <6

111
Q

Pathophys of anticholinergic OD?

A

Block muscarinic & nicotinic R’s
CNS blockage —> excitation/agitation
Central blockage —> hypermetabolic states
peripheral —> reduces sweat gland function

112
Q

Onset of anticholinergic OD?

A

Most 1-2hrs
*excluding long acting

113
Q

Duration of anticholinergic OD?

A

Mild resolves w/in 6hr
Severe or long acting: 1-2d

114
Q

Effects of anticholinergic OD?

A

Red as a beet (flush), Dry as a bone (dry skin/membranes), Blind as a bat (mydriasis w/ loss of accommodation), Mad as a hatter (AMS), Hot as a hare (fever), Full as a flask (urinary retention)

Other: widened QRS, tachycardia, hypoactive bowel, HTN, tremor, myoclonic jerk/seizures, ataxia

115
Q

TX for anticholinergic OD?

A

Activated charcoal 1g/kg kids, 50g adults
-Sodium bicarb for prolonged QRS
-Benzodiazepines for agitation/seizure

-Physostigime 0.5-2mg IV for both peripheral and moderate central anticholinergic toxicity
*avoid if purely tricyclic OD secondary to possible asystole

116
Q

Those at disposition for anticholinergic OD should be what?

A

Observe for mild sx, admit if severe

117
Q

Cause of serotonin syndrome?

A

Use of MAOIs w/in 5 wks of d/c fluoxetine, use of serotonergic agents w/in 2wks of d/c SSRIs

118
Q

Common OD SSRI meds with serotonin syndrome?

A

Sertraline, Fluoxetine, Paroextine, Citalopram, Escitalopram, fluvoxamine

119
Q

Common OD SNRI meds with serotonin syndrome?

A

Duloxetine, Venlafaxine

120
Q

Common OD MAOI meds with serotonin syndrome?

A

Phenelzine, Moclobemide, clorgyline, isocarboxazid, selegiline

121
Q

Common OD Tricyclic antidepressant meds with serotonin syndrome?

A

Amitriptyline, Nortriptyline

122
Q

Common OD (other) antidepressant meds with serotonin syndrome?

A

Trazadone, Nefazodone, Clomipramine, Triptans

123
Q

Common OD herbal supplements with serotonin syndrome?

A

Ginseng, St. John’s Wort

124
Q

Common OD meds of abuse with serotonin syndrome?

A

Amphetamines, ecstacy, LSD, cocaine

125
Q

Common OD miscellaneous meds with serotonin syndrome?

A

Dextromethorphan (cough med)

126
Q

Neuron phys/pathophys with serotonin syndrome?

A
127
Q

Pathophys of serotonin syndrome?

A

Meds cause inc serotonin production and uptake, as well as postsynaptic hypersensitivity

128
Q

Onset of serotonin syndrome?

A

50% w/in 2hr, 75% w/in 24 hrs

129
Q

Effects of serotonin syndrome?

A

-Mental status change: agitation, confusion, hypomania, delirium
-Autonomic instability: shiver, diaphoresis, midriasis, tachycardia, HTN, hyperthermia (104deg), hyperactive bowels
-Neuromuscular hyperactivity: hyperreflexia, tremor, clonus

130
Q

Work-up for serotonin syndrome?

A

Hx and PE, hx of serotonergic agent used w/in past 5 wks and exam w/ hypertonia, temp > 100.4, clonus

131
Q

Tx for serotonin syndrome?

A

D/c med (70% resolve in 24hr)
-Supportive: cooling, IV fluids
-Charcoal
-Benzos
-Cyproheptadine (antihistamine) PO or Chlorpromazine IV
-25% require intubation

132
Q

Ddx for serotonin syndrome?

A

Alcohol withdrawal, sympathomimetic abuse, meningitis/encephalitis, toxidromes

133
Q

Tx of BB OD?

A

Glucagon 1-2mg IV q5min prn

134
Q

Tx of CCB OD?

A

IV calcium gluconate (up to 4g) or IV calcium chloride (1g) and/or glucagon (5-10mg), +/- vasopressors

135
Q

Pharmacology of ETOH?

A

90% absorbed by 60min –> metabolized in liver at 20mg/dL/hr—> CNS depression via desensitized GABA and NMDA R’s

136
Q

Consequences of ETOH?

A

Inc. risk for esophageal, gastric, liver malignancy, gastritis, malnutrition, hepatosteatosis, hepatitis, fibrosis, inc. risk for HCV infection

137
Q

What is alcohol abuse?

A

Continued drinking despite adverse consequences, having alcohol related legal/social problems

138
Q

What is alcohol dependence (alcoholism)?

A

Physical cravings, withdrawal sx, need for more ETOH for intoxication

139
Q

What is alcohol withdrawal?

A

Physical sx a pt who has developed dependency experiences upon abrupt cessation

140
Q

Hx for ETOH?

A

-Type, amount
-Drinking pattern, frequency of >5 drinks/occasion
-Other drugs
-Complications of use, withdrawal sx
-CAGE tool

141
Q

What is the CAGE screening tool for ETOH?

A

Cut doen
Annoyed
Guilty
Eye-opener
(questions)
1 pt for each yes, 2+ concerning for abuse

142
Q

Effects of acute mild-mod intoxication of ETOH?

A

Loss of behavior inhibition, CNS depression, vasodilation (hypothermia, hypotension), tachycardia, resp. depression, diminished gag reflex, hypoglycemia, loss of fine motor

143
Q

Effects of acute severe intoxication (poisoning) of ETOH?

A

Loss of gross muscle control (ataxia, slurred speech), nystagmus, acute pancreatitis or gastritis, severe myocardial depression, lactic acidosis, pulm edema, loss of gag, arrhythmia/cardio collapse/sudden death

144
Q

Tx of acute alcohol intoxication?

A

-Assess ABCDE’s (and gag), sit upright if diminsished
-assess for secondary injury/aspiration
-Consider other drugs
-depression?

-Antiemetic: Zofran *least sedating
-Observe until clinically sober w/ stable VS and responsible adult
-IV fluids, dec time to sobriety

145
Q

ETOH withdrawal sx?

A

-Autonomic hyperactivity: tachycardia, HTN

146
Q

Tx for alcohol withdrawal?

A
147
Q

Management of alcohol withdrawal tx based on disposition?

A
148
Q

What is ethylene glycol?

A
149
Q

What is methanol?

A
150
Q

What is diethylene glycol?

A
151
Q

What is propylene glycol?

A
152
Q

What is isopropanol (isopropyl)?

A
153
Q

Tx for ethylene glycol ingestion?

A
154
Q

Tx for Propylene glycol ingestion?

A
155
Q

Tx for Isopropanol ingestion?

A
156
Q

Meds for memory???

A

Emergency Med Exam 1 (5 decks)

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