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702 > Toxicology Week 1 > Flashcards

Toxicology Week 1 Flashcards

1
Q

When should a hospital referral happen?

A
  • Moderate to severe exposure
  • Intentional ingestion
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2
Q

What are the ABCs of management?

A

Airway
Breathing
Circulation
Dextrose/Decontamination
EKG/Elimination

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3
Q

What are non-pharm options for toxic exposures?

A

Inhalational - remove from exposure area
Topical/dermal - irrigation with soap/water

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4
Q

T/F: We should utilize the gag reflex to remove toxic substances

A

FALSE

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5
Q

Which substances will not bind to activated charcoal?

A
  • Ionized metals (lithium)
  • Alcohols
  • Gasoline
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6
Q

What are some pearls of activated charcoal?

A
  • Sorbitol can improve palatability (only with one dose)
  • Must have protected airway
  • 1g/kg
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7
Q

What are some side effects of activated charcoal?

A

Vomiting, black tarry stools

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8
Q

Which decontamination strategy is useful for body packers or XR products?

A

Whole bowel irrigation

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9
Q

T/F: WBI is always best given by mouth

A

FALSE: an NG tube will eliminate the need for large volume consumption

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10
Q

When should you use orogastric lavage?

A
  • Potential to produce serious toxicity
  • No antidotes
  • Time window gives reason to believe agent may still be in the stomach
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11
Q

When should hemodialysis be used?

A
  • Other strategies unavailable/ineffective
  • Potential to produce serious toxicity
  • Agent dialyzable
    Basically last line
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12
Q

What does an anticholinergic toxidrome look like?

A
  • Dry mucous membranes
  • Flushed skin
  • Confused
  • Absent bowel sounds
  • Dilated pupils
  • Hyperthermia
  • Tachycardia
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13
Q

What is the antidote to anticholinergics?

A

Physostigmine (anticholinesterase inhibitor)
0.5 - 2 mg IV

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14
Q

What does a sedative-hypnotic toxidrome look like?

A
  • Normal vital signs
  • Very sleepy but can be woken up (painful stimuli)
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15
Q

What does an adrenergic/sympathomimetic toxidrome look like?

A
  • All vitals high
  • Agitated
  • Positive bowel sounds
  • Diaphoretic
  • Dilated pupils
  • Tremor
  • Agitated
  • Seizures
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16
Q

What does an opioid toxidrome look like?

A
  • Unresponsive to stimuli (even painful)
  • Respiratory rate very low
  • Pinpoint pupils
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17
Q

What does a cholinergic toxidrome look like?

A
  • Salivation
  • Lacrimation
  • Urination
  • Defecation
  • Gastric cramps
  • Emesis
  • Pinpoint pupils
  • Heavy oral secretions
  • Confusion
  • Bradycardia
  • Bronchorrhea
  • Bronchospasm
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18
Q

What are the most dangerous effects of the cholinergic toxidrome?

A

Killer Bs:
- Bradycardia
- Bronchorrhea
- Bronchospasm

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19
Q

How can we treat a cholinergic toxidrome?

A

Atropine 1 mg IV - titrate until bronchorrhea resolved

Pralidoxime - must administer before cholinesterase becomes inactivated

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20
Q

What are substances with unique toxidromes that we should always get a level for?

A

Acetaminophen (no toxidrome), salicylates

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21
Q

Which drugs will levels be important for treatment?

A
  • Digoxin
  • Vancomycin
  • Phenytoin
  • Lithium
  • Acetaminophen
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22
Q

Which 3 receptors do opioids act on?

A
  • Mu
  • Kappa
  • Delta
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23
Q

Which enzyme is important for codeine?

A

CYP2D6

24
Q

How do you treat an opioid overdose?

A
  • Administer antidote (naloxone)
  • Protect airway
25
Q

T/F: Intranasal naloxone will protect a patient’s airway immediately

A

FALSE: longer duration than IV but SLOWER onset

26
Q

Which dose of naloxone would you use for a non-opioid dependent patient?

A

0.4 mg IV

27
Q

Which dose of naloxone would you use for an opioid dependent patient?

A

0.04 mg IV, titrate to effect
(we do not want to precipitate withdrawal)

28
Q

What should we do if a patient is unconscious again after initial bolus of naloxone?

A

Give 1/2 of effective dose as bolus
Give 2/3 of effective dose per hour

29
Q

What is naloxone-induced pulmonary edema?

A

Catecholamine surge causing tachycardia, tachypnea, HTN
Blood shunts to lungs and causes fluid leakage into lungs

30
Q

How can we treat naloxone-induced pulmonary edema?

A

Nitroglycerin, diuretics, positive pressure ventilation
(Support their breathing)

31
Q

How can we prevent naloxone-induced pulmonary edema?

A

Smaller initial doses of naloxone (prevents surge)

32
Q

What does loperamide overdose look like?

A

Opioid overdose with cardiac arrhythmias

33
Q

Blockage of what transporter ehnances loperamide effects?

A

PGP (keeps it from crossing BBB)

34
Q

How do we treat loperamide overdose?

A

Naloxone (respiratory depression)

(for cardiac disturbances:)
IV magnesium
Sodium bicarbonate
IV isoproterenol
Transcutaneous pacing

CPR, ACLS

35
Q

How do we treat benzodiazepine overdose?

A

Monitoring, supportive care
(High therapeutic index, rare death)

36
Q

What are symptoms of benzodiazepine withdrawal?

A
  • Severe sleep disturbance
  • Irritability
  • Increased tension and anxiety
  • Panic attacks
  • Sweating
  • Difficulty in concentration
  • Dry retching and nausea
  • Palpitations
  • Headache
  • Psychotic reaction
  • Seizures
  • Death
37
Q

T/F: Benzodiazepine withdrawal is fatal but opioid withdrawal is not?

A

TRUE

38
Q

What is the antidote for benzodiazepines?

A

Flumazenil

39
Q

What is the dosing for flumazenil?

A

0.2 mg IV over 15 min
1-2 minute onset
Re-dosing maybe needed

40
Q

How can a benzodiazepine overdose possibly kill you?

A

Respiratory depression

41
Q

When should you use flumazenil?

A
  • Procedural sedation (known PMH)
  • Unintentional, pediatric exposure (with relative confidence of non-dependence)
42
Q

What are some sources of salicylates?

A
  • Pepto-Bismol
  • Alka-Seltzer
  • Icy hot
  • Bengay
  • Oil of wintergreen
43
Q

What is an acute overdose of salicylates?

A

> 150 mg/kg
(>500 mg/kg life threatening)

44
Q

How much methyl salicylate is in oil of wintergreen?

A

98g / 100mL

45
Q

Why do we have concern with renally impaired patients?

A

Renal elimination plays a greater role in significant overdose and has an extended half-life

46
Q

What are s/s of salicylate overdose?

A
  • Fast/shallow breathing
  • N/V, volume depletion
  • Hypoglycemia in brain
  • Tinnitus
  • Non-cardiogenic pulmonary edema (chronic)
  • Renal/hepatic injury
47
Q

What will help with CNS abnormalities in salicylate overdose?

A

Dextrose

48
Q

What acid/base progression can be seen in salicylate overdose?

A

Respiratory alkalosis -> metabolic and respiratory acidosis (breathing cannot compensate)

49
Q

What labs can be seen in salicylate overdose?

A
  • Abnormal blood sugar (but HYPOglycemia in brain)
  • Fluid/electrolyte losses
  • Increased anion gap
  • Positive urine ketones (utilized for energy)
50
Q

What does a chronic salicylate overdose look like?

A

More insidious onset
- N/V, tinnitus, dyspnea, hyperthermia, neurologic problems
- Increased PT/LFTs
- Lower levels will produce toxic effects (higher Vd)

51
Q

How could you treat salicylate overdose?

A

DO NOT INTUBATE
- Take multiple salicylate levels
- Multiple doses of activated charcoal
- Urine alkalization (pH > 7.5)
- Hemodialysis
- Treat adverse effects (seizures, cerebral edema, hypoglycemia, dysrhythmias)

52
Q

What supportive care should be given for salicylate overdose?

A
  • Give dextrose (even with normal glucose 0.5-1 g/kg)
  • Fluid maintenance (serum pH 7.45-7.55)
  • Urine pH > 7.5
  • Maintain potassium
  • Monitor (mental status, urine/blood pH, salicylate levels, fluid, electrolytes)
53
Q

How often should monitoring be done in salicylate overdose?

A

Every 2-4 hours

54
Q

When should hemodialysis be used in salicylate overdose?

A
  • Serum level (acute >100mg/dL, chronic >60mg/dL)
  • Neurologic deterioration
  • Seizures
  • Intractable acidosis (pH < 7.20)
  • Renal failure
  • Pulmonary edema
55
Q

When can you stop hemodialysis

A
  • Clear improvement in patient
  • Salicylate <19 mg/dL
  • HD completed for 4-6 hours and levels not obtainable

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