Section 3: General Management Principals

Question 1

3.1 Given an exposure, determine the appropriate disposition for the patient.

Answer 1

1. Consider general referral criteria and expected symptoms of described exposure to determine
   recommended disposition. Do not overthink. This is an application of a SPI’s daily duties.

Question 2

3.2 Identify the need for hemodialysis.

Answer 2

1. Consider the following examples:

Question 3

a. Acetaminophen:

Answer 3

Dialysis may be considered for very high levels (400-500) due to acidosis from drug metabolite.

Question 4

b. Aspirin:

Answer 4

Dialysis is considered for rising levels (80-100) associated with acidosis, altered mental status, pulmonary edema and hyperthermia

Question 5

c. Lithium:

Answer 5

Dialysis is considered for elevated BUN/Cr with significantly elevated Li level (ex > 4 mEq/L). It is used for significantly altered mental status, seizures, or dysrhythmias regardless of Lithium level.

Question 6

d. Metformin:

Answer 6

Dialysis is considered for rising lactic levels.

Question 7

e. Ethylene Glycol:

Answer 7

Dialysis is the definitive treatment to remove toxic alcohols and metabolites from the bloodstream.

Question 8

f. Alcohols:

Answer 8

Dialysis may be considered in life-threatening alcohol levels.

Question 9

g. Caffeine:

Answer 9

Dialysis is indicated for severe toxicity (seizures, ventricular dysrhythmias, or hypotension).

Question 10

h. Theophylline:
(Theo-24, Elixophylline, and Theochron)

*Theophylline has been used as a bronchodilator for asthma and COPD and is commonly used to treat neonatal apnea of preterm infants

Answer 10

Dialysis may be considered based on drug level and patient symptoms. Symptoms of concern include hemodynamic compromise, seizures, and mental status
changes.

*Increase catecholamine levels (epinephrine and norepinephrine) cause tachycardia, hypotension, anxiety and hyperglycemia. Adenosine receptor antagonism may cause seizures

Therapeutic level: 10-20 mcg/mL

Question 11

i. Valproic Acid:

Answer 11

Dialysis may be utilized in severe toxicity. In excessively high valproate levels (ex > 1000), protein binding is saturated, resulting in a higher free-valproate level
which may be dialyzed off.

Therapeutic level: 50-120 mg/L

Question 12

j. Selective Beta Blockers:

Answer 12

Dialysis may be potentially useful for overdoses of atenolol, sotalol and nadolol. These products have low Vd, low protein binding, and low molecular weight.

Question 13

3.3 Given a patient with a wide QRS interval on the ECG, identify the appropriate treatment.

Answer 13

1. A widening QRS interval (generally considered > 120 ms) indicates a Na-channel blockade.

When widened QRS interval is noted, evaluate pt’s hemodynamic stability (BP). Treatment is 1 amp or 50mEq of sodium bicarbonate; repeat ECG should show narrowing of interval if tox related.

Question 14

3.4 Given a seizing patient, identify the appropriate treatment.

Answer 14

1. For tox-related seizures, first line treatment is benzodiazepines.
2. If seizures are refractory, other options include barbituates, propofol, pyridoxine. Ensure
   hypoglycemia is ruled out by giving D50. Consider need for baclofen (if persistent seizures may
   be due to baclofen withdrawal).
3. Anti-epileptics may be used for non-tox related seizures or seizures of unknown origin.

Question 15

3.5 Given a patient with a dystonic reaction, identify the appropriate treatment.

Answer 15

1. Benadryl is generally the treatment for a dystonic reaction. Consider Haldol for some movement disorders related to antipsychotics (ex domapinergic medications).

Question 16

3.6 Identify the appropriate decontamination method for a given exposure (gastrointestinal, dermal,
ocular, or inhalation)

Answer 16

1. Gastrointestinal

Question 17

a. Activated charcoal:

Answer 17

i. Contraindicated for caustics and hydrocarbon ingestions.

ii. Does not work for: Lead, Iron, Lithium, Alcohols, Hydrocarbons, Caustics.

Question 18

b. Multi-dose activated charcoal may be considered with ingestion of the following
products:

Answer 18

i. Aspirin
ii. Carbamazapine
iii. Colchicine
iv. Dapsone
v. Phenobarbital
vi. Quinine
vii. Theophylline

Question 19

c. Gastric lavage

Answer 19

i. Occasionally used with massive ingestion of a product that is expected to cause
significant toxicity. Not recommended without a secure airway.

Question 20

d. Whole bowel irrigation

Answer 20

i. Ex for asymptomatic body packer, lead foreign body ingestion

Question 21

e. Emetics and cathartics

Answer 21

Rarely considered or used.

Question 22

2. Dermal

Answer 22

a. Mechanical washing with soap and running water for 10-15 minutes is generally appropriate. Powdered products should first be brushed off and contaminated clothes removed.

**Of note, some products such as powdered sodium azide react violently with water (this colorless salt is the gas-forming component in many car airbag systems).

Sodium Azide:
DECONTAMINATION

  Eye Exposure: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. 

  Dermal Exposure: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown.

Question 23

3. Ocular

Answer 23

a. 15 min ocular irrigation with tepid water, NS or LR.

Question 24

4. Inhalation

Answer 24

a. Fresh air and oxygen

Question 25

5. Enhancement of elimination may be performed through :

Answer 25

a. Alkalinization (ex bicarb drip for aspirin overdose)
b. Hemodialysis (ex toxic alcohol ingestion)
c. Multidose activated charcoal

Question 26

3.7 Given an exposure, identify contraindicated therapy.

Answer 26

1. Ex: Administration of activated charcoal is contraindicated in caustic or hydrocarbon ingestion.
2. Ex: Use of CPAP is contraindicated on a lethargic or vomiting patient.

Question 27

3.8 Identify expected adverse reactions and side effects of treatment.

Answer 27

1. Consider indications, contraindications, adverse effects, and monitoring parameters to antidote use.

Examples of expected reactions and SE of antidote treatment:

a. Anaplhylactoid reaction (rash) to NAC. Treat with Benadryl and decrease rate.
b. Hypokalemia from bicarb infusion (thus recommendation to add 40mEq of K to bicarb drip).

Question 28

3.9 Given an exposure, identify appropriate monitoring parameters.

Answer 28

1. Consider generally recommended monitoring times (per Micromedex) and type of monitoring (ex need for cardiac monitoring).