Toxicology + poisoning Flashcards by shawn wilde

True or false

organophosphates aggressively bind to cholinesterase molecules, stimulating their effect

false, they bind to cholinesterase molecules, inhibiting their effects and leaving acetylcholine unopposed in the neural synapses.

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a disease condition caused by the absorption of metabolic or bacterial poisons

Toxicosis

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Patient assessment for toxicosis can include (7)

If possible, access the bottle or container
Determine the medications that patient normally takes
Determine the time of exposure
Exposure acute or chronic
Determine if symptoms are related to the substance
Determine any prior treatment that was taken at home
Was the exposure intensional

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constellations of S/S that suggest a specific type of poisoning is generally called what

Toxidrome

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Cholinergic; symptoms of this toxidrome can be remembered with the acronyms

SLUDGE
DUMBELS
MTWT(H)FE

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Symptoms of this toxidrome include hypoventilation, hypotension, and miosis

opioid

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symptoms of this toxidrome include tachycardia, hyperthermia, and mydriasis

Anticholinergic

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what is the rhyme for anticholinergic toxidrome?

Hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter, the bowel and bladder lose their tone and the heart goes alone

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Sedative/ Hypnotic; common causes of this toxidrome include

benzodiazepines, barbiturates, and ethanol

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Sympathomimetic; common causes of this toxidrome include

amphetamines, cocaine, marijuana, and MDMA (ecstasy)

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Toxicology screens or panels for drugs of abuse usually detect
(8)

Amphetamines 
Barbiturates 
Benzodiazepines 
Cocaine 
Ethanol
Marijuana 
Opiates 
Phencyclidine (PCP)

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general interventions for toxicological emergencies include what
(5)

Gastrointestinal Decontamination, External decontamination, Syrup of Ipecac, Gastric Lavage, Activated Charcoal

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describe Gastric Lavage

has a limited benefit and is no longer used routinely. May be considered if the patient has taken a massive overdose or when the procedure can begin within 30 to 60 minutes of ingestion. Cannot be used to ingest large pills.
May be beneficial in patients who cannot absorb activated charcoal
Are known to produce significant morbidity.
Lavage must be in done with the patient lying on the left side

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describe Gastrointestinal Decontamination

accomplished through gastric lavage, the administration of charcoal or binding agents, and whole bowel irrigation

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describe External decontamination;

is accomplished through dermal or ocular decontamination

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what is Syrup of Ipecac? -

once a mainstay of therapy in poisoned patients in the ED and at home, but no longer recommended.
No longer recommended because it causes protracted vomiting, is implemented in Mallory-Weiss Tears and electrolyte imbalances, and delays activated charcoal administration

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Activated Charcoal, give 5 details

The preferred means of gastrointestinal Decontamination
Binds with chemicals and trap them before being absorbed
Best done without gastric emptying
May be used if the toxin cannot be identified
To be used as soon as possible after ingestion, most effective if within 60 minutes, especially if toxin is a sustained release medication

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activated charcoal Adverse effects include

Abdominal distension
Risk of aspiration
Constipation, particularly with anticholinergic toxicity
Nausea and vomiting

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Contraindications for activated charcoal include

Bowel Obstruction or perforation

CNS depression or seizures, unless the patient is intubated

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Substances that are poorly absorbed by charcoal include

Acids, alkalis, cyanide, ethanol, ethylene glycol, fluoride, iron, lead, lithium, mercury, methanol, mineral acids or salts, organic solvents, potassium, zinc
Small molecules and elements

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Indications for repeat does activated charcoal include ingestion of

Theophylline, Phenobarbital, Dapsone, Quinine, carbamazepine

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gastric lavage must be done with the patient in what position?

Lavage must be in done with the patient lying on the left side

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Other binding agents: this reduces the serum iron level

Milk of magnesia

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Other binding agents: this has been effective at limiting the serum lithium level

Sodium polystyrene sulfonate (Kayexalate)

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what is another name for Sodium polystyrene sulfonate

Kayexalate

The SLUDGE acronym stands for what?

Salivation, Lacrimation, Urination, Defecation, Gastrointestinal Distress and Emesis

The DUMBELS acronym stands for what? | What toxidrome does it refer to?

An acronym used to remember the common symptoms of certain affections of a cholinergic toxidrome: ("diaphoresis/diarrhea, urination, miosis, bronchospasm/bradycardia/bronchorrhea, emesis, lacrimation, salivation").

Opioid; Symptoms of this toxidrome include (3)

hypoventilation, hypotension, and miosis

Anticholinergic; symptoms of this toxidrome include (3) | What is the lyric that describes this toxidrome?

tachycardia, hyperthermia, and mydriasis Hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter, the bowel and bladder lose their tone and the heart goes alone

Sedative/ Hypnotic; common causes of this toxidrome include these (3)

benzodiazepines, barbiturates, and ethanol

Sympathomimetic; common causes of this toxidrome include (4)

amphetamines, cocaine, marijuana, and MDMA (ecstasy)

Toxicology screens or panels for drugs of abuse usually detect (8)

``` Amphetamines Barbiturates Benzodiazepines Cocaine Ethanol Marijuana Opiates Phencyclidine (PCP) ```

Gastrointestinal Decontamination - is accomplished through these three interventions

gastric lavage, the administration of charcoal or binding agents, and whole bowel irrigation

Syrup of Ipecac - what is it and why is it no loner used?

once a mainstay of therapy in poisoned patients in the ED and at home, but no longer recommended. No longer recommended because it causes protracted vomiting, is implemented in Mallory-Weiss Tears and electrolyte imbalances, and delays activated charcoal administration

``` Gastric Lavage - Is it still used? Who might benefit from it? In what timeframe should it be done? How should the patient be positioned? ```

has a limited benefit and is no longer used routinely. May be considered if the patient has taken a massive overdose or when the procedure can begin within 30 to 60 minutes of ingestion. Cannot be used to ingest large pills. May be beneficial in patients who cannot absorb activated charcoal Are known to produce significant morbidity. Lavage must be in done with the patient lying on the left side

Activated Charcoal The preferred means of ____ ____. Binds with chemicals and trap them before being ____. Best done without gastric emptying. May be used if the toxin cannot be ____. To be used as soon as possible after ingestion, most effective if within __ minutes, especially if toxin is a sustained release medication

gastrointestinal Decontamination absorbed identified 60

Adverse effects of Activated Charcoal include | 4

Abdominal distension Risk of aspiration Constipation, particularly with anticholinergic toxicity Nausea and vomiting

Contraindications of Activated Charcoal include | 4

Bowel Obstruction or perforation | CNS depression or seizures, unless the patient is intubated

Procedure for administration of Activated Charcoal includes

Measure the dose, mix with water and shake vigorously, give the mixture orally or with a gastric tube

Substances that are poorly absorbed by Activated Charcoal include (18) answers but generally what?

Acids, alkalis, cyanide, ethanol, ethylene glycol, fluoride, iron, lead, lithium, mercury, methanol, mineral acids or salts, organic solvents, potassium, zinc Small molecules and elements

Indications for repeat dose activated charcoal include ingestion of

Theophylline, Phenobarbital, Dapsone, Quinine, carbamazepine

Whole Bowel Irrigation entails the administration of an ____ ____ ____ (PEG) solution, such as ____, or ____, orally or through ____ ____ to remove the poison from the gastrointestinal tract as quickly as possible by ____ expulsion. Because ____ ____ is minimally absorbed, it is not likely to produce fluid and electrolyte imbalances.

``` Isotonic Polyethylene Glycol GoLYTELY Colyte gastric tube rectal polyethylene glycol ```

indications for the administration of an Isotonic Polyethylene Glycol (PEG) solution, such as GoLYTELY, or Colyte include (3)

Ingestion of drugs that are not well bound to charcoal Sustained release or enteric coated drugs Toxic solid objects, such as balloons or condoms filled with cocaine or heroin

contraindications for the administration of an Isotonic Polyethylene Glycol (PEG) solution, such as GoLYTELY, or Colyte include (6)

``` Bowel obstruction Ileus Gastrointestinal hemorrhage Absent gag reflex unless intubated Compromised airway Hemodynamically unstable ```

Procedure for the administration of an Isotonic Polyethylene Glycol (PEG) solution, such as GoLYTELY, or Colyte include

Protect the patients airway Insert a gastric tube if the patient will not or cannot drink the prescribed amount of solution Administer 1 to 2 L per hour for an adult, half that for pediatric, orally through a gastric tube until the rectal effluent is clear or the FB has passed

Dermal Decontamination When is it indicated? Why should you not use a neutralizing agent? When is it contraindicated?

Indicated when the skin has been exposed to toxic substances Do not use a neutralizing agent because it may cause an exothermic reaction that produces heat Contraindicated in exposure that might react with water, such as phosphorus. Consult the poison control center or a hazardous materials professional if you have questions about the substance.

``` Dermal Decontamination what is the first thing you do? What is the second thin you do? Brush away ___ substances Rinse all areas of contact and skin folds with copious water for __ to __ minutes. What is the last thing you do? ```

``` Don PPE Remove clothing from the patient Dry 20 to 30 Properly dispose of contaminated clothing ```

Ocular Decontamination Flush with ___ or ____ ____ solution for __ to __ minutes, until a pH of __ is achieved. This is tested through the use what?

NSS or lactated ringers 20 to 30 7 of a pH strip by touching the lower eyelid gently with the strip

Enhancing Elimination After taking steps to eliminate absorption, the next priority in managing a toxicologic emergency is the enhancing of the elimination of the absorbed toxins. What are 5 procedures you can do?

``` Repeat dose of charcoal Urine alkalinization Hemodialysis Charcoal hemoperfusion Continuous hemofiltration ```

Urine Alkalinization | Manipulates the pH of urine to enhance the excretion of certain drugs such as (6)

Chlorpropamide (glipizide), 2,4-Dichlorophenoxyacetic acid, formate, methotrexate, phenobarbitol, salicylates

Urine Alkalinization Procedure Administer ____ ____ as prescribed During treatment, monitor the urine pH how often? Adjust to keep the urine pH between __ and __. Administer ____, as prescribed, to avoid ____

``` sodium bicarbonate hourly 7.5 and 8.0. potassium hypokalemia ```

Urine Alkalinization Adverse effects (6)

Hypernatremia, hypokalemia, alkalosis, fluid overload and pulmonary edema, QT prolongation (as shown in the image) and other dysrhythmias resulting from the electrolyte shift

Enhancing Elimination Hemodialysis , Hemoperfusion, and Hemofiltration All three not only remove the ____ and ____ from the circulation, they also rapidly and effectively correct ____ and ____ imbalances. Indications include the removal of these substances (13)

``` toxins metabolites acid-base electrolyte Acetaminophen (tylenol), antibiotics, bromide, ethanol, ethylene glycol, isopropanol, lithium, methanol, paraquat, phenobarbitol, salicylates, theophylline, digoxin ```

Enhancing Elimination Hemodialysis , Hemoperfusion, and Hemofiltration Reserved for what type of situations?

Reserved for poisonings that may be lethal or cause severe acidosis, such as chronic salicylate poisoning

Antidote Administration | Acetaminophen (tylenol);

N-acetylcysteine (Mucomyst)

Antidote Administration | Anticholinergics;

Physostigmine (Antilirium)

Antidote Administration | Benzodiazepines;

Flumazenil (romazicon)

Antidote Administration | Beta-blockers;

Glucagon (GlucaGen)

Antidote Administration | Calcium channel blockers;

Glucagon, calcium chloride, calcium gluconate (Calgonate, insulin (Humalog), and glucose

Antidote Administration | Carbon monoxide;

Oxygen

Antidote Administration | Cyanide;

amyl nitrite, sodium nitrite, sodium thiosulfate, and hydroxocobalamin

Antidote Administration | Digitalis preparations;

Digoxin immune FAB (Digibind, DigiFab)

Antidote Administration | Ethylene glycol;

Fomepizole (Antizol) and ethanol infusion

Antidote Administration | Heavy metals;

Ethylenediaminetetraacetic acid (EDTA), dimercaprol (BAL in oil) and penicillamine (Depen)

Antidote Administration | Heparin;

Protamine Sulfate

Antidote Administration | Iron (Fesol); Deferoxamine (Desferal)

Deferoxamine (Desferal)

Antidote Administration | Isoniazid (INH);

Pyridoxine (vitamin B8)

Antidote Administration | Methanol;

Deferoxamine, fomepizole, and ethanol infusion

Antidote Administration | Nitrates (ie; Nitrostat);

Methylene Blue

Antidote Administration | Opiates;

Naloxone (Narcan)

Antidote Administration Atropine and pralidoxime (2-PAM) Organophosphates;

Atropine and pralidoxime (2-PAM)

Antidote Administration | Sulfonylureas;

Octreotide (Sandostatin)

Antidote Administration | Tricyclic antidepressants;

Sodium Bicarbonate

Antidote Administration | Warfarin (Coumadin);

Phytonadione (vitamin K)