Toxidromes 4

Question 1

Tricyclics overdose presentation (6)

Answer 1

1. Initially similar to anticholinergic toxidrome
2. Occurs early: usually within 4 hours
3. Mortality related to Life threatening events
4. Cardiac: Ventricular arrhythmias
5. CNS toxicity: Seizures, coma
   * Seizures are worse than cardiac arrythmias b/c they can kill you instantly
6. MUST DO AN ECG!!!!!!!!!!!!!!
   * Very toxic, only needs a small dose to be bad for you → could lead to death

Question 2

What do you see on ECG with tricyclic overdose? (4)

Answer 2

i. Prolonged QT
ii. Large QRS wave
iii. Sinus tachycardia with tall R in R
iv. QRS wave is tall and wide

Question 3

TCA Overdose: General Info (6)

Answer 3

1. Leading cause of death by intentional overdose
2. Blocks sodium channels
3. Death by cardiovascular dysrhythmias and cardiovascular collapse
4. Most TCA’s have anticholinergic effects – Dry skin, blurry vision, hot
5. Severe OD: hypotension, seizures, respiratory depression
6. In severe cases: ARDS, rhabdomyolisis, DIC

Question 4

TCA Overdose: Management (4)

Answer 4

1. Management: Multiple charcoal doses
2. Assess risk in well appearing patient

Normal vital signs and LOC:

3. Traditional dose of concern is >l0 mg/kg
4. Rule of thumb: concern is greater if greater than 5 therapeutic doses are ingested

Question 5

TCA Evaluation of Well-Appearing Patient (6)

Answer 5

1. Assess vital signs and LOC
2. Cardiac monitor for rhythm and QRS duration
3. IV placement
4. Gut decontamination
5. Observe 6 hours after ingestion
6. Can discharge if psychiatric clearance and VS, LOC, and ECG are normal throughout the observation period

Question 6

Ill-Appearing Patient with TCA Poisoning (4)

Answer 6

1. Assess and stabilize if needed
2. Monitor vital signs and LOC
3. Venous access, ABG and cardiac monitor playing attention to QRS
4. Correct acidosis with NaHCO3

Question 7

Treatment of TCA Overdose (4)

Answer 7

1. Sodium Bicarbonate
   a. Titrate for serum pH of 7.45-7.5
   b. Because TCA is alkaline
2. IV fluids
3. Lidocaine for persistent arrhythmias
4. AVOID Class IA drugs (procainamide quinidine)

Question 8

What is Alkalization Effect? (4)

Answer 8

1. Alkalization of serum may help with specific toxins
2. Salicylates – facilitates elimination and keeps toxin out of the tissues
3. Tricyclic antidepressants
4. Methanol intoxication

Question 9

Iron overdose: general info (4)

Answer 9

1. Most common cause of poisoning death in children over 6
2. MOST DIFFICULT TO TREAT

Mechanism of Toxicity

3. Potent oxidizer and catalyst of free radical formation
4. Saturation of metabolic pathways results in the production of excess toxic metabolite that is hepatoxic and nephrotoxic

Question 10

Iron overdose signs and symptoms (5)

Answer 10

1. Stage 1: GI symptoms: abd. pain, vomiting hematochezia and hematemesis within two hours of ingestion
2. Stage 2: Stable but evidence of hypoperfusion and acidosis
3. Stage 3: Acidosis, shock
4. Stage 4: Hepatotoxicity with 48 hours of ingestion
5. Stage 5: Bowel obstruction from inflammation and stricture formation occurring 2-4 weeks following ingestion

• Will get acidotic, hepatotoxic and bowel obstruction
• Will have stricutres
• There are long-term effects even if they survive the

Question 11

Iron overdose assessment (3)

Answer 11

Doses of concern:

1. Child >40 mg/kg
2. Adolescent: Any dose over l.5 grams
3. If there is a lack of gut symptoms within 6 hours, likely to be a nontoxic ingestion

Question 12

Iron overdose management (3)

Answer 12

1. Get Abdominal x-ray: central
   i. If normal and well, likely non-toxic ingestion
   ii. If abnormal, perform gut decontamination –> Go LYTLEY works well
2. Gut decontamination
   i. Whole bowel irrigation
   ii. No bicarbonate or phosphate or oral deforoxamine
3. Volume support

Question 13

what shows up on x-ray with iron overdose? (5)

Answer 13

1. Chloral hydrate and cocaine packets
2. Opiate packets
3. Iron and other heavy metal such as lead arsenic and mercury
4. Neuroleptics
5. Sustained release or enteric coated tablets
   * Can see lead and iron on X-Ray! Including the pills – you’ll know how many pills they ingested

Question 14

Iron overdose plan of care for w/ info (4)

Answer 14

1. Obtain serum iron concentration
   a. Likely serial needed
   b. Not TIBC
2. Indication for chelation therapy –> Clinical symptoms of GI, altered mental status, metabolic acidosis and hypotension
   * Serum iron >400 ug/dL; Monitor
   * IV Deferoxamine is iron chelator
3. Shock and acidosis
   a. Multifactorial nature of shock
   b. Hypovolemia: from GI loss
   c. Distributive: iron mediated vasodilation
   d. Cardiogenic: Cardiac suppression
4. Acidosis
   a. Can be profound
   b. Etiology is hydration of nonbound plasma iron lactic acidosis
   c. Requires large amount of bicarbonate

Question 15

Iron overdose: other effects (8)

Answer 15

1. Patient will be acidotic with slight hyperglycemia
2. Leukocytosis
3. Metabolic acidosis
4. Iron pills in stomach may be visible on KUB
5. Order CBC, glucose serum iron, blood gas, chem screen (include LFT’s)
6. IRON does not bind to charcoal
7. If there within l5-30 minutes, syrup of ipecac
8. If in first one-2 hours, can lavage Whole bowel irrigation: GoLYTELY

Question 16

Iron: Serious Overdose (4)

Answer 16

1. Deferoxamine: chelation
2. If significant metabolic acidosis, or iron pills on x-ray
3. If iron level > 500 micrograms/dL
4. Given by continuous infusion then taper usually 24 hours

Question 17

Caustic Alkali (2)

Answer 17

1. Household cleaning products most common exposure
   a. Children < 6 years
   b. Start talking to parents about this at 4-6 months – safety precautions
2. Most common cause of morbidity
   a. Alkali Drain Cleaners
   b. Acid toilet bowl cleaners

Question 18

Acid and Alkali Toxicity: What follows initial injury with ingestion? (5)

Answer 18

a. Thrombosis of vessels
b. Heat production through neutralization
c. Bacterial invasion
d. Inflammatory response with granulation tissue formation
e. Scar retraction at 3 weeks to months with subsequent stricture formation

Question 19

Affected sites with acid and alkali toxicity (5)

Answer 19

a. Oropharynx, Esophagus, stomach are most common
b. Alkali more often cause esophageal lesion
c. Acids more often cause gastric lesions
d. Many exceptions since usually multiple sites

e. Must open up the mouth, look in the back of the throat, look at the pharynx, etc, if you can’t see anything then the patient needs to get scoped
* If you need a scope, call GI rather than ENT because it’s an ingestion

Question 20

Clinical presentation of acid and alkali toxicity (5)

Answer 20

1. Absence of respiratory distress does not preclude the existence of airway burns
2. The absence of oropharyngeal burns does not preclude the presence of esophageal burns
3. Pain: oral, retrosternal abdominal
4. Dysphagia, drooling, vomiting, stridor
5. Oropharyngeal and laryngeal burns

Question 21

Acid and Alkali Ingestion Evaluation (4)

Answer 21

1. History: identity, concentration, volume, time, circumstance
2. Physical: AIRWAY, oropharyngeal
3. Lab: depends on severity
4. Fiberoptic endoscopy for all symptomatic or in asymptomatic child with a strong history

Question 22

Acid and Alkali Ingestion Management (6)

Answer 22

a. Airway stable
b. Vascular access
c. Poison control center
d. Decontamination
e. Supportive care
f. Psychiatric evaluation