Toxicology

Question 1

what must be considered when dealing with toxic pt?

Answer 1

dose (manifestations may be related to how much they took)
route
intentional/unintentional
time elapsed (how long has it been since you took this?)

Question 2

snorting

Answer 2

insluphation

Question 3

toxidromes

Answer 3

toxic substance

Question 4

AMS

Answer 4

altered mental status (frightened, agitated, delerium)

-overdose should always be in the differential when a pt presents with this

Question 5

differential of AMS

Answer 5

AEIOUTIPS
alcohol/acidosis
electrolytes/epilepsy
infection (sepsis, elderly)
opiates/overdose
uremia (kidney failure)
trauma/toxicity/tumor
insulin (hypoglycemic/hyperglycemic)
psych
stroke

Question 6

steps to manage patient

Answer 6

ABC -airway (protect it proactively)
D-decontamination (remove garments)
E-easily correctable issues (hypoglycemia, hypoxia, hypotension, hypo/hyperthermia)

Question 7

what is the most common OTC overdose?

Answer 7

acetaminophen

Question 8

what organ does acetaminophen affect?

Answer 8

liver

encephalopothy

Question 9

what is the max dose in people of acetaminophen?

Answer 9

4gms (adults)

90mg/kg (children)

Question 10

toxicity is assoc with what dose of acetaminophen

Answer 10

150mg/kg

Question 11

what is the first stage of acetaminophen overdose?

Answer 11

stage 1: asymptomatic, anorexia, nausea/vomiting, LFTs (liver enzymes) rise in the first 24 hours

Question 12

what is the 2nd stage of acetaminophen overdose?

Answer 12

18-24 hrs post ingestion
RUQ pain
continued rise in LFTs and aPTT
oliguria (urine output drops)
tachycardia
hypotension

Question 13

what is the 3rd stage of acetaminophen overdose?

Answer 13

72-96 hrs post ingestion
continued abdominal pain
hepatic necrosis and encephalopathy (due to rising ammonia levels because liver can’t break down nitrogenous wastes of protein synthesis)
jaundice
GI bleeding
LFTs peak, ammonia and bilirubin continue to rise

Question 14

what is the 4th stage of acetaminophen overdose?

Answer 14

4dys -2weeks
resolution of hepatic abnormalities of liver failure
LFTs come down

Question 15

what lab studies will you order with acetaminophen overdose?

Answer 15

CBC
CMP
arterial blood gasses (ABG)
acetaminophen level (recheck every 4 hrs)
U/A
RUQ ultrasound (grossly enlarged gallbladder?)
CT of the head (with evidence of encephalopathy)
EKG (for baseline)

Question 16

what are examples of salicylates?

Answer 16

aspirin
pepto-bismol
oil of wintergreen

Question 17

what drug is taking the place of aspirin as a common overdose drug?

Answer 17

anti-depressants

Question 18

what is the early presentation of aspirin OD?

Answer 18

early (1-2 hrs post ingestion)

• tinnitus
• vertigo
• Nausea/Vomiting/Diarrhea
• hyperpyrexia
• coma

Question 19

what is the later presentation of aspirin OD?

Answer 19

hypernea
blood gas abnormalities
-respiratory alkalosis (CO2 is leaving the body)
-metabolic acidosis
-cerebral edema (AMS)
(cleared in the liver and kidney)

Question 20

what labs do you order for aspirin OD?

Answer 20

salicylate levels
CBC
CMP
LFT
ABG (blood gasses)
UA
(protein will go up, spill blood in the urine)

Question 21

what are the normal/abnormal levels of salicylate?

Answer 21

110 mg/dL severe toxicity

Question 22

what are exampels of opioids

Answer 22

codeine
morphine
hydrocodone
oxycodone
heroine

Question 23

what is the presentation of opioid OD?

Answer 23

respiratory depression
pinpoint pupils (lost light reaction-no dilation)

Question 24

when are the peak effects of opioid with IVs?

Answer 24

10 min with IV route

Question 25

when are the peak effects of opioid with insufflation?

Answer 25

10-15 min

Question 26

when are the peak effects of opioid with IM administration? (intermuscular)

Answer 26

30-45 min

Question 27

when are the peak effects of opioid with oral ingestion?

Answer 27

90 min

Question 28

when are the peak effects of opioid with dermal application?

Answer 28

2-4 hours

Question 29

what labs should you order with opioid OD?

Answer 29

``` CBC CMP ABG toxicity screen-often times qualitative (opioids, canabis, salycilates, acetaminophen) abdominal film (body packers) ```

Question 30

what is the peak effect of cocaine via inhalation?

Answer 30

1-5 min

Question 31

what is the peak effect of cocaine via IV?

Answer 31

3-5 min

Question 32

what is the peak effect of cocaine via nasal?

Answer 32

15 min

Question 33

what is the peak effect of cocaine via oral?

Answer 33

60 min

Question 34

what is mild presentation of cocaine OD?

Answer 34

euphoria agitation tachycardia hypertension

Question 35

what is moderate presentation of cocaine OD?

Answer 35

``` stroke renal ischemia seizures ventricular dysrhythmias apnea cyanosis hyperthermia coma death ```

Question 36

what are the physiologic affects of cocaine

Answer 36

vasoconstrictor cardiotoxic long term use = constrictive cardiomyopathy

Question 37

what labs would you order with cocaine OD?

Answer 37

``` CBC CMP UA EKG (baseline) tox screen ```

Question 38

what are examples of benzodiazepines

Answer 38

``` valium xanax ativan klonopin librium (older, not used as much) tranxene (older, not used as much) -extremely addictive, designed for short, acute,use ```

Question 39

presentation of benzo OD?

Answer 39

``` coma with normal vital signs nystagmus (horizontal typically) hallucinations slurred speech ataxia (stumble, clumsy gait) AMS agitation Respiratory depression ```

Question 40

what labs would you order with benzo OD?

Answer 40

CBC ABG tox screen (if suspect multiple ingestion) no set test to identify benzos in blood or urine

Question 41

what are examples of antidepressants?

Answer 41

tricyclics - elavil - pamelor - tofranil - vivactyl

Question 42

presentation antidepressant OD?

Answer 42

``` CNS sedation confusion delirium hallucinations cardiac arrhythmias (widened QT interval-ventricular dysrythmias ) ```

Question 43

what labs would you order for antidepressant OD?

Answer 43

``` EKG tox screen (nothing else involved) TCA levels (qualitative only) salicylate levels acetaminophen levels ```

Question 44

ethanol

Answer 44

ETOH

Question 45

BAC of 0.01-0.1 presents with

Answer 45

euphoria mild coordination deficits attention and cognition

Question 46

BAC of 0.1-0.2 presents with

Answer 46

coordination deficits and psychomotor skills, decreased attention, slurred speech, ataxia, impaired judgment and mood variability

Question 47

BAC of 0.2-0.3 presents with

Answer 47

lack of coordination, incoherent thoughts, confusion and nausea and vomiting

Question 48

BAC of >0.3 presents with

Answer 48

stupor and loss of consciousness coma respiratory depression and death

Question 49

what is a common complication of vomiting while drunk?

Answer 49

aspiration

Question 50

things to consider with ETOH

Answer 50

BAC may not correlate with S & S | watch out for respiratory depression

Question 51

labs for ETOH

Answer 51

ETOH level ABGs tox screen (if something else is going on)

Question 52

why is carbon monoxide dangerous?

Answer 52

it has a greater affinity for hemoglobin compared to oxygen (300 times greater)

Question 53

presentation of acute CO poisoning

Answer 53

``` headache (most common) malaise nausea dizziness can be misdiagnosed as ETOH intoxication chest pain (AMI) ```

Question 54

presentation of long term CO poisoning

Answer 54

``` cognitive deficits personality changes movement disorders (ataxia that doesn't resolve)and focal neurological deficits ```

Question 55

what social group has higher levels of CO?

Answer 55

smokers

Question 56

labs for CO poisoning?

Answer 56

Pulse ox is NOT reliable, cannot distinguish between O2 and carboxyhemaglobin ABGs (smokers may have 10-15% baseline)