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Clin Med Final Material- Semester 2 > Toxicology: Ross--> check quizlet > Flashcards

Toxicology: Ross--> check quizlet Flashcards

1
Q

Goals of general Management

A
  • Get the Exposure: EMS history
  • Get the time of ingestion
  • Substance and Amount Pill –Bottles in order to count
  • Why the ingestion?
  • History from patient in a quiet setting without peers
  • Be a detective, ask the same question in different ways to family/friends
  • What symptoms?
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2
Q

Criteria for Nontoxic Ingestion

A
  • Only one substance
  • Must have absolute identification
  • Exposure is unintentional

-Symptom free for obs period
Easy follow up

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3
Q

Overdose deaths (#1 cause?)

A 
Opioids= #1
Sedative /hypnotics/antipsychotics
Cardiovascular
Stimulants
Alcohols
Acetaminophen
Antidepressants
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4
Q

Listen for red flags

A

Hx:

  • suicide attempt–> Concern: Multiple substances, delayed action
  • Tricyclic antidepressant–> high morbidity and mortality
  • Beta blocker or CCB
  • Vomiting with LOC–> airway compromise
  • Lithium, aspirin. theophyline, toxic alcohols–> may require dialysis
  • Muschroom or acetominophen ingestion –> High morbidity and mortality
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5
Q

Vitals: (questions?)

A
  • Brady or tachy?
  • hyper pr hypotension?
  • Temp?
  • must undress
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6
Q

Bradycardia/hypotension is caused by:

A

-b blockers calcium channel blockers, Digoxin, clonidine, organophosphates, ethanol opioids

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7
Q

Tachy/ Hypertension caused by?

A

sympathomimetics, anticholinergics, theophylline, nicotine , thyroid

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8
Q

Hyperthermia caused by?

A

-salicylates, anticholinergics, sympathomimetic, withdrawal states, NMS and serotonin syndrome

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9
Q

Bradypnea caused by?

A

Sedatives, ethanol, opiods

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10
Q

Tachypnea caused by?

A

Salicylates,metabolic acidosis, paraquat,chemical pneumonitis

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11
Q

Physical Exam:

  • eyes?
  • Skin?
  • RR?
A

Eyes: state pupillary size and reaction to light
Skin: wet or dry (check armpits/groin)
RR
Neurological : muscle tone and conscious state
Bowel function: hyper/hypo
Bladder: retention

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12
Q

Increased muscle tone–> associated with which drug class?

A

amphetamines, phencyclidine, antipsycotics, ssri

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13
Q

Flaccid tone:

-assoc with?

A

sedative-hypnotics, narcotics, clonidine

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14
Q

Rigid tone: assoc with?

A

haloperidol, phencyclidine,strychnine,NMS

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15
Q

Tremor:

-associated with?

A

lithium, nicotine stimulant overdose or sedative-hypnotic withdrawal

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16
Q

Seizures:

-associated w?

A

TCA, amphetamines, phenothiazines,lindane,isoniazid,pesticides

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17
Q

Absorption:

-describe first pass?

A

first pass metabolism hepatic portal circulation through liver greatly reduces bio-availability

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18
Q

Distribution=

A

how substance is transported to tissue

**volume of distribution

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19
Q

Elimination=

A

Elimination: excreted or biotransformation with kidneys and liver primarily responsible

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20
Q

Supportive Management:

-includes assessment of ______

A
  • *Mental Status and Ability to continue respiratory function is KEY
  • Airway and central function of breathing
  • During the first hours patient needs multiple re-evaluations of respiratory function
  • Does patient need a reversal agent, how can we enhance elimination
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21
Q

SAGE=

A

Supportive care: ABC

antidotes: “coma cocktail” and table 47-10

gastric decontamination: removal (ipecac, lavage, and charcoal)

Elimination: dialysis, urinary excretion, hemofiltration

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22
Q

Altered Mental Status:
AEIOU TIPSS

KNOW

A

Alcohol,electrolyte,insulin,oxygen,opiate,uremia,trauma,infection, psychosis,stroke,seizure

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23
Q

Coma Cocktail:

(contains?) KNOW

A 
Coma cocktail= DONT
D-dextrose (D50)
O- Oxygen 
N- Naloxone (0.1mg-0.4 mg, IV, IM, SQ)
-Thiamine- 100mg IV
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24
Q

Pitfall of Naloxone

A

-We said earlier many opioid ingestions are coupled with benzodiazepine
Naloxone will reverse opioid but NOT benzo
-so potential to reverse opioid possibly put in mild withdrawal state but still sedated from Benzo.
-*AIRWAY NIGHTMARE
Have airway adjuncts or think about intubations

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25
Q

For gastric Decontamination will Ipecac work?

A

nope

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26
Q

_____ is better for decontamination

A

charcoal**

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27
Q

The general thinking is Not to use _____ (this product) ever

A
  • *Ipecac
  • Does more harm than good
  • Needs to be administered immediately to do any good takes about 20 min to work
  • Possible role in Prehospital setting with a serious Iron, Lithium
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28
Q

Gastric Decontamination: Lavage

“Pump the Stomach

A
  • This procedure should never be done alone
  • Many complications
  • Indications are rare to never
  • -Fatal ingestions that arrive within 60 min of ingestion AND are not absorbed by charcoal
  • -Such as…. Iron, Lithium, Large amounts of salicylate, ingestion of sustained release products,
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29
Q

Enhance Elimination:

-when is charcoal useful?

A

**Useful for up to 1-2 hours post ingestion unless the drug is enteric coated or a slow release then 2nd doses needed

-Prevents absorption of drug and in acetaminophen enhances elimination through the enterohepatic pathway

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30
Q

Charcoal:

-how good is it?

A

=BEST form of decontamination

-low risk

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31
Q

Describe Charcoal

A
  • highly porous substance which absorbs toxins

- **best given < 60 min of ingestion no longer routine management

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32
Q

Contraindications for charcoal include:

A
  • Decreased Mental Status
  • Very lethal if aspirated so the patient must be able to drink or consider intubation
  • Hydrocarbon ingestions
  • Corrosives
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33
Q

Charcoal:

-adverse effects?

A
  • Adversely can cause nausea so always give with an anti-emetic, ex. Zofran
  • Contraindicated when there is a suspicion of GI perforation such as ingestion of a corrosive, hydrocarbons
  • Dose is 1g/kg with sorbitol, subsequent doses are without sorbitol.
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34
Q

Charcoal:
Multiple doses with sorbitol are not beneficial unless one of these folks
—THESE PATIENTS SHOULD DRINK CHARCOAL QUICKLY

A

THEOPHYLLINE, PHENOBARBITAL SALICYLATES, DAPSONE CARBAMAZEPINE QUINIDINE

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35
Q

Charcoal

Not helpful for :

A

Iron
Lithium
Lead
Or other small molecules

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36
Q

Whole Bowel Irrigation

A

copious
iron
lithium
packers

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37
Q

Enhancing Elimination : Hemodialysis

A
  • low protein binding
  • small volume of distribution

-Good for these OD:
salicylate, lithium, methanol, isopropanol, ethylene glycol, theophylline

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38
Q

Systematic Evaluation:

-what do you do first?

A

Respiratory Function First, Vital Signs next, MS

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39
Q

Systematic Evaluation:

-Has the PT ingested a lethal dose?

A

=**LD50
-is there an antidote?

  • Decontamination Principles:
  • -Toxicity depends of absorbed dose of toxin
  • -does this pt need charcoal/WBI/dialysis?
40
Q

Who should you always call?

A

CALL your LOCAL Poison Center

ROCKY MOIUNTAIN POISON CONTROL

41
Q

Labs to order for overdose cases

A

Labs: BMP, Mag level, alcohol level, tylenol , ASA

Utox??
Does not measure a lot of substances
exrohypnol, or MDNA

42
Q

Labs:

-common false positives

A

Amphetamines: pseudophedrine

TCA: diphenhydramine

PCP: ketamine, dextromethorphan

43
Q

Labs:

-common false negatives?

A
  • dilute urine

- Rohypnol: benzo

44
Q

Treatments for absorption:

-Decrease absorption

A

-charcoal,wbi

45
Q

Treatments for absorption:

-enhance elimination?

A
  • Alkalinizing with bicarbonate
  • Salicylate-urine
  • Dialysis
46
Q

Treatments for absorption:

-Prevent peripheral Effects

A

Antidotes: Narcan, Digi-bind, Fab fragments, chelation therapy, amyl nitrate

47
Q

General Management

Unknown Ingestion

A

-Toxidrome: table 47.2 :
(NEED TO KNOW THESE)

-Sympathomimetic (SNS also called adrenergic)
-Opioid
-Anti-Cholinergic ( anti-parasympathetic)
-Salicylate
-Hypoglycemia
Serotonin Syndrome

-If unknown agent look for a pattern within the vital signs and physical exam to tease out an agent

48
Q

Toxidrome: Anticholinergic

  • Presentation?
  • V/S changes?
  • Causative agents?
A
  • Delirium, Flushed skin, dilated pupils, **Hot as a hare, Dry as a bone, Red as a beet, Blind as a bat*
  • V/S changes: Tachy, Hyperthermia, HTN
  • Antihistamines, Scopolamine, Jimson weed, Benzotropine, TCAs, atropine
49
Q

Toxidrome: Opiate/narcotic

  • Presentation?
  • V/S changes?
  • Causative agents?
A
  • AMS, Unresponsive, Miosis, shock
  • Shallow respirations, slow resp rate, brady, hypothermia

-Opiates, Dextromethorphan

50
Q

Toxidrome:

Cholinergic

A

?

51
Q

Toxidrome:

Sympathomimetic

A

?

52
Q

Unknown OD:

-LOOK FOR anion ____

A

**gap acidosis: VBG and BMP

53
Q

MUDPILES

A

Methanol, uremia, DKA, propylene glycol, INH iron,lactic acidosis,ethylene glycol,ethanol (alcoholic keto acidosis), rhabdo, salicyclates

54
Q

CHIPES

A 
Chloral hydrate, Calcium carbonate
Heavy metals
Iron
Psychotropic, packets,potassium
Enteric-coated and slow release
Solvents

THESE all have radiopaquents visible

55
Q

Osmolar gap=

A

measured -calculated
Dont memorize this:
Calculated osmols= 2(na) + glucose/18+ bun/2.8+etoh/4.6

56
Q

be able to calculate anion gap?

A

?

57
Q

Opiote antidote=

A

naloxone

58
Q

Organophosphates (antidote)=

A

atropine

59
Q

Cyanide (antidote)=

A

Sodium Nitrite and sodium thiosulfate

60
Q

Benzodiazepine= (antidote?)

A

flumazinil(rarely given)

61
Q

Flumazenil is really only intended for ?

A

single intoxicant and with kids

  • avoid in general
  • mixed intoxicants really avoid

-complication includes intractable seizures

62
Q

Toxidrome: Sympathomimetic

  • Sx?
  • Tx?
A

-Sx: Stimulants, HTN, Tachycardic, Seizures

-Amphetamines activate the adrenergic system with with alpha and beta receptor activity
increases release of norepinephrine, epinephrine, dopamine and serotonin

-TX: Benzodiazapines**
and intubate possibly

63
Q

WHAT DO YOU NOT GIVE a person that overdosed on sympathomimetic? (stimulants)

A

DO NOT GIVE THEM BETA BLOCKERS

-**Treatment Pitfall: Beta blockade gives un-opposed alpha activity

64
Q

Ex’s of stimulants

A
  • cocaine

- amphetamines )ie ecstasy, bath salts, smokeable meth

65
Q

MDMA=

  • describe
  • tx for overdose?
A 
=Molly “molecular”  or Ecstasy,
Hallucinogen
--releases large amount of serotonin
serotonin triggers oxytocin and vasopressin
the love trust and empathy hormones
also amphetamine like affect

-Hyperthermia, psychomotor agitation, delirium

tx=cooling and benzodiazepines

66
Q

19y/o college student
Doesn’t “feel well” has runny nose, cough x 2 days. Roommate states he hasn’t been acting right for about 4 hours. no drugs or etoh
otc meds
Anxious, agitated

WHAT DO YOU WANT TO KNOW?

A

Is he maintaining his airway? What are his vitals? 140/70, 138, 20, 97%, 100.1

GET VITALS, AIRWAY

67
Q

Pt with anti-cholinergic overdose will have what Sx?

A 
**hot as hell, blind as a bat, dry as a bone, red as beet, mad as a hatter
Tachycardia, hyperthermia
Mydriasis, can’t accommodate
Dry skin and mucus membranes
also Urinary retention, decreased bowel sounds
AMS
Wide QRS
Hallucinations: to agitated delirium
68
Q

anticholinergic cardiac toxicity: **usually tachycardias only
-Wide complex tachycardia, sodium channel blockade: tx?

A

sodium bicarbonate

69
Q

Torsades de points: tx?

A

magnesium

70
Q

Ventricular Dysrhythmia: tx?

A

lidocaine

71
Q

What med can treat any anti cholinergic OD?

A

physostigmine* can reverse all sx BUT, you must make sure there are no other drugs on board

72
Q

Major S/E of physostigmine=

A

seizures**

73
Q

OD DDx:

A
  • encephalitis
  • head trauma
  • withdrawal
74
Q

Management of the Agitated Patient who you believe is in a Substance abuse psychosis or just plain psychotic

A

Vital sign check is important

-Hx as much as feasible: AMPLE

-approach in SAFEST manner
space, appearance, focus, exchange, stabilize and treat

75
Q

test Question:

if alcoholics are in withdrawal and very agitated: tx?

A

benzos

-give antiipsychotic if they arent in withdrawal

76
Q

Test question:

  • amphetamine OD:
  • Anticholinergic OD:
A

BENZOS= tx

77
Q 
Test question:
CNS depressant( ie alcohol) OD: tx?
A
  • antipsychotic med (HALDOL) or 2nd gen Planzapine –> these meds can prolong QT
  • BUT Must know what their QT is
78
Q

B52=

A

commonly used,

it’s a combo of benzo 5mg and haldol 2mg

79
Q

Agitated Delirium=

A

=Paranoia, Hallucinations and Disorientation

-Hyperthermia

  • Seemingly superhuman strength
  • -unclear pathophys: Hyper K, and cpk with positional asphyxia

-chronic drug abuse (stimulants)

80
Q

Agitated Delirium: tx?

A

benzo and check electrolytes

81
Q

28 yo male biba after “friend” found him asleep in his room and could not arouse him. On arrival EMS noted shallow respirations as well as miosis. Pt had gone to work the day prior and seemed “ok”. No other hx known.
PMH: back pain post mva 1 yr ago
meds: unk
110/50,99,8,90% and 96.8, lethargic with minimal response to pain.
pt has an iv started and no meds

A

Steps:

  • IV O2 monitor
  • Naloxone

ask questions:
-is this suicide?
-is this someone trying to get high
-

82
Q

CNS depression, Hypothermia, Bradycardia, Miosis=

A

Toxidrome= CNS depression
OPIOIDS!!!!!

Deaths are most commonly from methadone, oxycodone and morphine.
Usually associated with diversion and provider shopping.

83
Q

Acetaminophen OD is due to the build up of which toxic metabolite?

A
  • n-acetyl-p-benzoquinoneimine (NAPQI)

- causes hepatocellular necrosis

84
Q

Acetaminophen OD: tx?

A

repletion of glutathione stores with N-Acetylcysteine NAC (precursor to glutathione)
po and **iv forms

85
Q

4 Phases of Acetaminophen OD toxicity:

A

0-24 hours: stage one; GI symptoms n/v

24-48 Quiet stage: asymptomatic; rise of transaminases, liver tenderness

72-96 hours stage 3: Jaundice and Hepatic encephalopathy, death

4 days to ?? May survive with liver failure or resolution of symptoms RING OF FIRE Stage

86
Q

Rumack-Matthew nomogram

for toxicity:

A

use within first 24 hrs of acetaminophen toxicity (plasma levels)

87
Q

Acetaminophen OD:

-rule of 4’s (but just got changed to 150)

A
  • 150 mg/kg= toxic dose
  • 4 hour level greater than 150 ug/mL= toxicity

-150 mg/kg of N-Acetylcysteine (NAC) mucomyst PO or IV : loading dose then a 2 and 3rd doses

88
Q

Acetaminophen OD:

-decontaminate w/?

A
  • charcoal**
  • tx if NAC with levels >20

**BUT NAC is useful even after 24 hours after toxicity

89
Q

ASA overdose: bottom line?

A

Pts develop a severe metabolic acidosis with a respiratory alkalosis**
-and tinnitus

90
Q

THINGS TO KNOW:

A

ethanol : drink with ethyl: no acidosis (unless starved)

methanol: windshield wiper, paint strippers
acidosis (it forms formic acid) with large osmolar gap: blind

isopropyl: rubbing alcohol
ketosis with no acidosis

ethylene glycol: antifreeze, de-icers–> acidosis with gap: renal failure, urine crystals

91
Q

Serotonin Syndrome:

-

A

most often with therapeutic doses of SSRI
Cognitive, neuromuscular and autonomic dysfunction rigidity, lethargy and fever
Similar presentation to NMS 9less severe) with Hyperthermia, muscle rigidity with clonus, hyper-reflexia, shakes and cognitive dysfunction
difference is hyperreflexia and clonus
Precipitated by med increase or administration of serotonergic drugs (merperidine)

92
Q

SSRI : serotonin syndrome

tx?

A

**Cyprohepatidine is an H1 receptor antagonist but also blocks serotonin at the 5-HT1A and 5-HT2A receptor

93
Q

Things that Kill Peds in Small Doses

A 
TCA
Camphor
Methyl salicylate (wintergreen oil)
Calcium channel blockers
**Sulfonylureas: oral hypoglycemics
Clonidine
Lomital
Vision: alpha 2 agonist
94
Q

Sulfonylureas

A

=children can become proudly hypoglycemic

-need admission to watch

-do not autonomically give glucose (this will cause the release of insulin) if glucose is
low then give

95
Q

Neuroleptic Malignant Syndrome=

tetrad of distinct clinical features:

A

**fevers

**rigidity: will lead to elevated CPK

**mental status changes
autonomic instability

(hyperthermia will kill them if they are left untreated)

-caused by antipsychotics**

Tx: dantroline**

Clin Med Final Material- Semester 2 (22 decks)

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