Toxicology + poisoning Flashcards
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.
a disease condition caused by the absorption of metabolic or bacterial poisons
Toxicosis
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
constellations of S/S that suggest a specific type of poisoning is generally called what
Toxidrome
Cholinergic; symptoms of this toxidrome can be remembered with the acronyms
SLUDGE
DUMBELS
MTWT(H)FE
Symptoms of this toxidrome include hypoventilation, hypotension, and miosis
opioid
symptoms of this toxidrome include tachycardia, hyperthermia, and mydriasis
Anticholinergic
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
Sedative/ Hypnotic; common causes of this toxidrome include
benzodiazepines, barbiturates, and ethanol
Sympathomimetic; common causes of this toxidrome include
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)
general interventions for toxicological emergencies include what
(5)
Gastrointestinal Decontamination, External decontamination, Syrup of Ipecac, Gastric Lavage, Activated Charcoal
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
describe Gastrointestinal Decontamination
accomplished through gastric lavage, the administration of charcoal or binding agents, and whole bowel irrigation
describe External decontamination;
is accomplished through dermal or ocular decontamination
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
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
activated charcoal Adverse effects include
4
Abdominal distension
Risk of aspiration
Constipation, particularly with anticholinergic toxicity
Nausea and vomiting
Contraindications for activated charcoal include
Bowel Obstruction or perforation
CNS depression or seizures, unless the patient is intubated
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
Indications for repeat does activated charcoal include ingestion of
Theophylline, Phenobarbital, Dapsone, Quinine, carbamazepine
gastric lavage must be done with the patient in what position?
Lavage must be in done with the patient lying on the left side
Other binding agents: this reduces the serum iron level
Milk of magnesia
Other binding agents: this has been effective at limiting the serum lithium level
Sodium polystyrene sulfonate (Kayexalate)
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)
