Overview Questions Flashcards
The most common significant, acute clinical effect noted thus far in ACE Inhibitor overdose is:
a.Hyperkalemia secondary to a decrease in aldosterone secretion.
b.Angioedema of the head and neck.
c.Hypotension developing within one hour of exposure.
d.Acute renal failure and nephrotic syndrome.
e.Hepatic dysfunction, usually cholestatic in nature.
C - Most commonly seen is a drop in BP.The other symptoms listed are not common at all.
Angioedema has been reported with therapeutic use of ACE Inhibitors. All of the statements are true of this condition EXCEPT which of the following:
a.Angioedema is usually present in the head and neck especially the face, lips, tongue and glottis.
b.Initial pharmacological intervention with epinephrine, antihistamines and steroids is recommended but not always effective.
c.If angioedema is unresponsive to pharmacological intervention, oral or nasal intubation may be necessary.
d.Angioedema in the setting of ACE Inhibitor ingestion is believed to be related to a drug allergy and is frequently accompanied by urticaria.
e.Angioedema in the setting of ACE Inhibitor ingestion is believed to be a biochemical reaction related to bradykinins rather than an immunologic response.
D - It is well known that drug allergy is NOT the cause of angioedema.
Which of the following statements is FALSE concerning observation and treatment during overdose from ACE Inhibitors:
a.Monitor serum electrolytes, especially potassium and sodium.
b.Hemodialysis is expected to be effective in eliminating ACE Inhibitors, but has not been necessary in documented cases thus far.
c.ACE Inhibitor levels correlate well with toxicity by these agents.
d.Monitor hepatic and renal function.
e.Hypotension associated with ACE Inhibitor overdose usually will manifest within one hour of ingestion.
C - Patients may remain asymptomatic despite high serum ACE inhibitor drug levels. Serum levels don’t correlate with toxicity.
Side effects reported with therapeutic use of the ACE Inhibitors include all of the following EXCEPT: a.Angioedema. b.Respiratory depression. c.Cough. d.Hyperkalemia. e.Hyponatremia.
B - PI does not make mention of respiratory depression as a common side effect or symptom.
Which of the following clinical manifestations would not be related to acute acetaminophen overdose:
a.metabolic acidosis.
b.hematological changes including thrombocytopenia.
c.seizures.
d.persistent emesis and pancreatitis.
e.renal insufficiency and acute tubular necrosis.
C - Neurologic signs and symptoms are rarely seen in APAP overdoses.
The Matthew-Rumack nomogram is helpful in assessing the potential risk of acetaminophen overdose and the indication for NAC therapy. Which of the following statements is TRUE concerning the use of the Matthew-Rumack nomogram?
a.Acetaminophen levels exceeding 150 mcg/ml may be used to assess the need for NAC therapy even when drawn before four hours post-exposure. This is based on the fact that any acetaminophen level exceeding this threshold limit indicates the need for NAC therapy.
b.Acetaminophen levels after CHRONIC ingestion cannot be plotted on the nomogram with any accuracy.
c.Do not give NAC until a toxic level has proven the need for the antidote since it may not be discontinued once instituted, under any circumstances.
d.When subsequent acetaminophen levels after an initial toxic four hour level fall into the low risk toxicity range, NAC therapy may be safely withdrawn if liver enzymes are closely monitored on a daily basis.
e.Levels after CHRONIC ingestion may be accurately plotted on the Matthew-Rumack Nomogram when the level is drawn at least four hours after the last dose.
B - The R-M nomogram is not designed to evaluate chronic APAP ingestions.
Pregnant women ingesting acetaminophen in overdose amounts place the fetus at risk for acetaminophen toxicity. Specifics to consider when assessing these exposures do NOT include:
a.Acetaminophen is known to cross the placenta and fetal liver cells are capable of metabolizing acetaminophen, thus putting the fetus at risk for hepatotoxicity.
b.Fetal blood levels of acetaminophen after maternal overdose have been shown to be equal to that of the mother.
c.NAC, the antidote for acetaminophen overdose, has been shown to undergo placental transfer in pregnant rats, theoretically making it available to the fetus for protection of the liver.
d.Maternal acetaminophen overdose is a definite indication for termination of the pregnancy once the NAC protocol is completed.
e.Rapid treatment of the mother with NAC is the best way to treat the fetus in the setting of acetaminophen toxicity. Delayed treatment, especially in the first trimester, has been associated with the poorest fetal outcomes.
D – Administering NAC to the mother as soon as possible after the overdose is the most effective means of preventing hepatotoxicity in mother and fetus
Recalcitrant emesis is a troublesome symptom of acetaminophen toxicity in part because it impairs the ability to deliver the NAC antidote orally. Approaches to the management of this problem include all of the following EXCEPT:
a.The institution of an intravenous protocol for NAC therapy.
b.Administration of antiemetics such as ondansetron, metoclopramide, or droperidol as a pretreatment to NAC therapy.
c.Decreasing the dilution of the NAC dose so that a smaller volume of solution will be delivered. Solutions of NAC as high as 10-20% have been instituted with better retention due to the smaller volume.
d.Insertion of a nasogastric tube into the stomach to deliver the dose of NAC over a 30-60 minute period.
e.If emesis continues, the NG tube may be advanced into the duodenum for the delivery of NAC.
C - Decreasing the dilution would increase the emesis potential.
Late presentation (>24 hours) of the acetaminophen overdose patient poses a multitude of management decisions for the SPI. The following statement is FALSE concerning management considerations in this setting: a.After 24 hours post-ingestion, the interpretation of acetaminophen blood levels is questionable. b.The use of NAC should be strongly considered in late presentation acetaminophen overdose in those patients with detectable acetaminophen levels or biochemical evidence of hepatotoxicity. c.The Matthew-Rumack nomogram may be helpful in assessing late presentation acetaminophen overdoses by plotting the level at the 24 hour mark. d.NAC dosing follows the same dosing protocol for late presentation as for early presentation: A loading dose of 140 mg/kg NAC as a 5% solution, followed by 70mg/kg NAC as a 5% solution at every 4 hour intervals for 17 maintenance doses. e.NAC therapy instituted as late as 36 to 80 hours after acetaminophen ingestion has been shown to improve clinical outcome and survival rates in acetaminophen overdose.
C - The R-M nomogram is not helpful in assessing late presenters. Other factors like preexisting conditions, LFTs, PT/INR, etc. would need to be considered.
A 3 year old, 30 pound child arrives in ED, tachycardic with heart rate of 170 bpm sinus rhythm, agitated, and nervous. According to mom, the child has ingested 60cc of albuterol sulfate syrup about thirty minutes ago. What lab work would you want to monitor on this child? a.Potassium and glucose levels b.Theophylline level c.Glucose and chloride levels d.Arterial blood gases e.Cardiac enzymes
A - Significant decreases in serum potassium can occur following intravenous or oral administration of albuterol in high doses. Hyperglycemia is observed following albuterol administration, with diabetic ketoacidosis occurring in susceptible individuals.
Which of the following statements about treatment of albuterol exposures is true?
a.Treatment should begin with IV glucose and bicarbonate administration.
b.Administration of propranolol may be effective in reducing palpitations and associated anxiety.
c.Hemodialysis is an effective treatment in overdose situations.
d.Rinsing the mouth after inhalation of albuterol will decrease the occurrence of muscle tremors in asthmatic patients.
e.Because of the slow absorption rate of liquid albuterol, ipecac would be an effective decontamination agent.
B – Administration of propranolol may be helpful in reducing palpitations and anxiety in the patient with an albuterol overdose. Propranolol is contraindicated in patients with bronchial asthma and severe COPD.
All of the following symptoms can occur in overdose of sympathomimetics except for: a.Hypertension b.Ischemic EKG changes c.Supraventricular tachycardia d.Pulmonary edema e.Miosis
E - Sympathetic stimulation from systemic or ocular exposures to sympathomimetic drugs will usually result in mydriasis not miosis.
A nurse administering Brethine (terbutaline) to a patient mistakenly sticks the needle into the tip of her thumb and injects some of the medication. Which of the following statements concerning this exposure is true?
a.Central nervous system depression may occur.
b.Atropine should be given to decrease the tachycardia.
c.Surgical opening of thumb should be attempted to remove any medication in area.
d.Accidental subcutaneous autoinjection of a digit may result in severe vasoconstriction with numbness and paleness.
e.Other than pain at site, no effect is expected.
D - Significant vasoconstriction resulting in numbness and paleness of the left index finger occurred following subcutaneous epinephrine autoinjection of the digit.
Which of the following statements concerning exposures to albuterol is FALSE?
a.Overdose cases are generally considered to produce symptoms which are extensions of the adverse effect.
b.Patients may have tachycardia or hypertension.
c.Arterial hypoxemia can be exaggerated if albuterol is used in excess.
d.Young children who receive albuterol syrup may experience CNS depression.
e.Significant hypokalemia can occur following intravenous or oral administration of albuterol in high doses.
D - Adverse effects include tachycardia, premature ventricular contractions, palpitations, tremor, agitation, nervousness, headache, dizziness, insomnia, hyperglycemia, hypoglycemia, nausea, and vomiting.
1.Amphetamine overdose is LEAST likely to cause which of the following toxic manifestations? a.Tachycardia b.Seizures c.Hypotension d.Mydriasis e.Hyperthermia
1.C - Systolic and diastolic hypertension are common and may be postural.
2.Which of the following laboratory tests is likely to be of LEAST value in assessing the symptomatic patient following an amphetamine overdose? a.CPK b.Liver enzymes c.Renal function tests d.Amphetamine levels e.Serum electrolytes
2.D - Most members of the amphetamine family and related diet pill constituents are difficult to detect in the plasma unless very large amounts have been ingested, as in chronic abusers.
3.Acidification of the urine is not recommended following overdose of amphetamines because it may precipitate: a.Renal failure b.Seizures c.Hallucinations d.Liver failure e.Ascites
3.A - Acidification enhances amphetamine excretion but may precipitate acute renal failure in patients with myoglobinuria and is CONTRAINDICATED.
4.Which of the following is used as a street name for methamphetamines? a.“Crank” b.“Speed” c.“Ice” d.“Meth” e.All of the above
4.E - SLANG TERMS associated with methamphetamine: “speed,” “crystal,” “crank,” “meth,” and “ice”.
1.Of the antibiotics used today, which group is most commonly associated with causing drug induced renal failure? a.Penicillin b.Cephalosporins c.Tetracyclines d.Aminoglycosides e.Sulfonamides
D – aminoglycosides. Rationale: “The incidence of nephrotoxicity post treatment with aminoglycoside antibiotics is estimated to be 5 – 100%” Goldfrank’s, 1998, pg 759.
Examples:
gentamicin, tobramycin, amikacin, plazomicin, streptomycin, neomycin, and paromomycin
.The combination of which of the following antibiotics and ethanol may produce a disulfiram-type reaction? a.Gentamicin b.Metronidazole c.Amoxicillian d.Erythromycin e.Ampicillin
B – metronidazole (Flagyl). Rationale: Per Drugdex®, some persons taking metronidazole experience disulfiram-like reactions when using alcohol. Probable mechanism inhibition of acetaldehyde metabolism.
3.A 2-year-old child weighing 14 kg ingested two ounces of his amoxicillin 250mg/5ml suspension. Which of the following is the most appropriate recommendation?
a.Dilute and observe in the home setting
b.Multiple dose activated charcoal
c.Whole bowel irrigation
d.Hemodialysis
e.Gastric lavage
3.A –dilute and observe in the home setting.
1.A lengthening of the prothrombin time is commonly seen with an overdose of warfarin. This lengthening may be evident within \_\_\_ hours of the exposure and peak in \_\_\_ hours. a.6 hours/24 hours b.12 hours/24 hours c.24 hours/36-72 hours d.36 hours/144 hours e.48 hours/144 hours
1.C. - 24 hours/36-72 hours. This correlates with the half life of factor VII.
2.Warfarin and related compounds interfere with clotting factor synthesis by blocking the vitamin K- dependent gamma-carboxylation of glutamic acid residues in precursors of all of the following clotting factors EXCEPT: a.II b.III c.VII d.IX e.X
2.B – III
Warfarin and warfarin-like oral anticoagulants mechanism of action involves Vitamin K inhibition. Vitamin K is a cofactor in the postribosomal synthesis of clotting factors II, VII, IX and X.
3.The initial treatment of choice for a patient with active blood loss after an overdose of a long acting anticoagulant would be: a.Activated charcoal b.Fresh frozen plasma c.Menadione d.Menadiol e.Observation
3.B – fresh frozen plasma.
4.All of the following statements are true in regards to an overdose of a long acting anticoagulant EXCEPT:
a.Bleeding may be the first manifestation of toxicity.
b.The diagnosis is typically an easy diagnosis, if there is a history of exposure.
c.Anticoagulant effects of warfarin can be expected to disappear within a few days; reports concerning human exposures to brodifacoum have been associated with clinical bleeding for more than 6 months.
d.Slow systemic clearance and a large volume of distribution may explain brodifacoum’s prolonged effect.
e.Administration of vitamin K1 as antidote to anticoagulant poisoning is NOT effective.
D – brodifacoum: Vd = 0.985L/Kg in rats.
1.Gabapentin is an antiepileptic drug indicated as an adjunct to current antiepileptic therapy in adults. All of the following are true statements EXCEPT:
a.The mechanism of action of gabapentin remains unknown.
b.Peak plasma concentrations occur 2-4 hours after ingestion.
c.Gabapentin binds to the plasma proteins and is metabolized by the liver.
d.Gabapentin is primarily excreted by the kidneys as unchanged drug.
e.Gabapentin is a well-tolerated antiepileptic agent that has some mild CNS effects.
1.D - Gabapentin is not metabolized and is excreted unchanged by the kidneys
2.Which of the following statements about phenytoin is CORRECT:
a.At plasma concentrations below 10mg/L, elimination is linear (first order).
b.At plasma concentrations below 10mg/L, elimination is zero order.
c.At plasma concentrations below 10mg/L, elimination is second order.
d.At plasma concentrations below 10mg/L, elimination is by Michaelis-Menten kinetics.
e.At plasma concentrations below 10mg/L, elimination is totally by the kidneys.
A - At therapeutic levels, elimination is first-order. In an overdose, saturation of the hepatic hydroxylation system may occur and result in elimination following Michaelis-Menten kinetics. A prolonged half-life is the result when this occurs.
3.Which of the following is NOT likely to be seen with an oral overdose of phenytoin? a.Nystagmus b.Ataxia c.Dysrhythmias d.CNS depression e.Vomiting
- C – Cardiotoxicity is unlikely following an oral overdose of phenytoin. Cardiotoxicity HAS been reported following the IV administration of both phenytoin and fosphenytoin.
* SEVERE TOXICITY: Large oral ingestions can cause more severe CNS depression, coma, and, rarely, respiratory depression. Rapid infusion of the parenteral formulation (faster than 50 mg/min) can cause hypotension, bradycardia, AV conduction delays, and ventricular dysrhythmias which may be fatal. It is felt that the cardiotoxicity of the intravenous formulation of phenytoin is secondary to the diluent, propylene glycol, and not the phenytoin itself.
1.A 182 pound male was just admitted to a rural hospital ICU following an acetaminophen overdose 12 hours earlier. The attending physician wrote orders for Mucomyst to be given. The nurse caring for this patient calls the poison center for information on how much Mucomyst she should be dosing. All she knows is that she can obtain a 20% solution from the pharmacy. For this patient, what are the loading dose and maintenance doses she will need to give?
a.127 cc loading dose, 64 cc maintenance dose
b.58 cc loading dose, 58 cc maintenance dose
c.58 cc loading dose, 29 cc maintenance dose
d.65 cc loading dose, 32 cc maintenance dose
e.127 cc loading dose, 127 cc maintenance dose
1.C – Dosing for NAC therapy is 140 mg/kg loading dose, followed by maintenance doses of 70 mg/kg. This patient weighs 82.7 kg, so the loading dose would be 11,582 mg and maintenance doses would be 5,792 mg.20% Mucomyst contains 200 mg/ml (20% equals 20 grams per 100ml). Divide the dose required by the concentration of the solution to get the volume of drug needed.
2.A child was exposed to his mother’s prenatal iron tablets. In the ED, the stomach was emptied, and a serum iron concentration drawn 3 hours after the ingestion was 358 mcg/ml. The child was vomiting, drowsy, and had an arterial pH of 7.24. The physician ordered deferoxamine to be given. Which of the following statements concerning deferoxamine therapy is CORRECT?
a.The indication for deferoxamine is when the SI is greater than the TIBC
b.The dose is 15 mg/kg deep IM every 4 hours until the urine changes color
c.Deferoxamine 15mg/kg/hr IV for 72 hours for SI levels greater than 350 mcg/ml
d.Sepsis has been associated with the administration of deferoxamine
e.Deferoxamine therapy must be given IM to avoid venous infiltration
D – Yersinia enterocolitica septicemia has been associated with the administration of deferoxamine in iron-overdosed children.
3.The chelator dimercaprol (BAL) is FDA approved for toxic exposures to which of the following? a.Lead, iron and cadmium b.Arsenic, gold and mercury c.Arsenic, mercury and uranium d.Lead, copper and iron e.Mercury, gold and selenium
3.B – Arsenic, gold and mercury.
Dimercaprol (BAL) is also FDA approved for the treatment of lead poisoning.
4.A patient having attempted suicide with captopril is in the ED, being decontaminated. The MD calls the poison center for the name of the appropriate antidote. What course of action would the specialist recommend?
a.You advise the physician that calcium is the physiological antagonist to increase myocardial contractility.
b.You advise the physician that administration of glucagon would be an appropriate therapy for this patient.
c.You advise the physician that flumazenil is the drug of choice for symptoms of CNS depression and hypotension.
d.You advise the physician that this is always a nontoxic ingestion and no therapy is indicated.
e.You advise the physician that they should monitor for hypotension, and manage with Trendelenburg position and IV fluids.
4.E – ACE inhibitors generally cause mild hypotension that can usually be treated with IV fluids and positioning.
Examples:
Capoten (captopril) Vasotec (enalapril) Prinivil, Zestril (lisinopril) Lotensin (benazepril)
5.Which statement concerning the use of antidotes is INCORRECT?
a.Flumazenil may be of utility in the treatment of benzodiazepine overdose, although seizures may occur if a tricyclic antidepressant has been co-ingested
b.The “Universal Antidote” consisting of burned toast, strong tea, and Milk of Magnesia serves no purpose in modern day toxicology.
c.Glucose, naloxone, and oxygen should be considered for any patient who is found unresponsive in the absence of a known toxin.
d.Pralidoxime is of greatest utility in the treatment of poisonings due to pyrethroid insecticides.
e.Digibind (FAB) is indicated for rhythm and conduction disturbances, refractory hyperkalemia, and digoxin level 10-15 ng/ml in acute ingestions.
- D – Pralidoxime is used in the treatment of organophosphate poisonings.
1.Which of the following drugs should be avoided when treating dysrhythmias associated with an overdose of procainamide? a.Sodium bicarbonate b.Lidocaine c.Quinidine d.Magnesium sulfate e.Isoproterenol
1.C – Quinidine. Quinidine is a class Ia antiarrhythmic, as is procainamide. Co-administration may result in further prolongation of the QT interval and induce torsades de pointes.
Note: Procainamide –
Class Ia antiarrhythmic; sodium channel blocker
2.Which of the following medications does NOT have a potentially major interaction with quinidine that could result in toxicity? a.Acetazolamide b.Clarithromycin c.Digoxin d.Disulfiram e.Itraconazole
2.D – Disulfiram. Disulfiram has not been shown to have an interaction with quinidine. Acetazolamide decreases the clearance of quinidine, while clarithromycin and itraconazole decrease the metabolism resulting in potentially toxic levels. Co-administration of digoxin and quinidine may result in significantly increased digoxin levels and resultant toxicity.
1. Which of the following drugs would be most appropriate for initial control of seizures caused by a toxic ingestion of an antihistamine? a.Phenobarbital b.Diazepam c.Fosphenytoin d.Gabapentin e.Valproic acid
1.B – Diazepam. Benzodiazepines are the initial therapy of choice for control of seizures in this instance. Phenobarbital should be considered for refractory or recurrent seizures. Benzodiazepines and barbiturates are generally preferred over phenytoin or fosphenytoin for the control of drug-induced seizures.
2.Which of the following antihistamines is LEAST likely to cause CNS depression when taken in overdose? a.Hydroxyzine b.Diphenhydramine c.Promethazine d.Loratadine e.Clemastine
- D – Loratadine.
Loratadine has a low incidence of CNS depression. All other choices have a moderate to high incidence.
1.A drug which may be used to increase blood pressure and heart rate in both calcium channel blocker and beta adrenergic blocker overdose is: a.Procainamide b.Sodium nitroprusside c.Hydralazine d.Glucagon e.Nitroglycerin
1.D - Glucagon produces positive inotropic, chronotropic and dromotropic effects. It may be used to increase blood pressure and heart rate in both calcium channel blocker and beta adrenergic blocker overdose.
2.A patient who is a victim of clonidine overdose may have symptoms that mimic those in a patient who has overdosed on which of the following classes of drugs? a.Opiates b.MAO inhibitors c.Amphetamines d.Salicylates e.ACE inhibitors
2.A - Clonidine is a centrally acting adrenergic inhibitor that stimulates alpha 2 adrenergic presympathic (inhibitory) receptors in the brain. Toxic effects resemble opiate like toxicity with generalized CNS depression. Naloxone may be useful in reversing the effects although it has not always produced consistent effects.
3.Hypokalemia would be most commonly associated with overdose due to: a.Digoxin b.Propranolol c.Hydrochlorothiazide d.Captopril e.Clonidine
3.C - Hydrochlorothiazide is a thiazide diuretic which causes hypokalemia.
4.A patient who has overdosed on an unknown quantity of sustained release verapamil 240mg tablets has been lavaged, yet numerous tablets can still be visualized on an abdominal X-ray. Which of the following should be considered? a.Peritoneal dialysis b.Hemodialysis c.Whole bowel irrigation d.Charcoal hemoperfusion e.Exchange transfusion
4.C - Whole bowel irrigation. This may be useful in sustained release calcium channel blocker overdoses if visualized on abdominal x ray.
Examples:
Amlodipine (Norvasc) Diltiazem (Cardizem, Tiazac, others) Felodipine. Isradipine. Nicardipine. Nifedipine (Adalat CC, Procardia) Nisoldipine (Sular) Verapamil (Calan, Verelan)
5.Bronchospasm may be induced in the asthmatic patient who has taken an overdose of: a.Clonidine b.Verapamil c.Nifedipine d.Furosemide e.Propranolol
5.E - Propranolol is a non-specific beta blocker which may produce bronchospasms in patients with asthma or bronchospastic disease because it blocks B receptors in the lungs.
1.Blindness is a toxic effect most commonly associated with which of the following? a.Digoxin b.Theophylline c.Quinine d.Colchicine e.Lithium
1.C – Quinine has a direct toxic effect on photoreceptor and ganglion cells in the retina that can produce blurred vision impaired color perception, constriction of visual fields and permanent blindness in some patients.
2.Early signs and symptoms of quinine poisoning may be mistaken for toxicity due to : a.Acetaminophen b.Propranolol c.Diltiazem d.Aspirin e.Amitriptyline
2.D - Aspirin – quinine may produce nausea, vomiting, and “cinchonism” {tinnitus, deafness, vertigo, headache, and visual disturbances} which resemble aspirin toxicity.
3.Of the following, the best choice in the treatment of cardiac conduction defects associated with quinine poisoning is: a.Sodium bicarbonate b.Quinidine c.Procainamide d.Bretylium e.Disopyramide
3.A - Sodium bicarbonate – the sodium ion and alkalemia produced reverses the sodium channel dependent membrane depressant “quindine” like effects.
4.Enhanced elimination of quinine following an overdose would best be accomplished through the use of: a.Hemodialysis b.Peritoneal dialysis c.Charcoal hemoperfusion d.Multiple dose activated charcoal e.Forced alkaline diuresis
4.D - Multiple dose activated charcoal (MDAC) may be beneficial according to the latest position statement for MDAC. Other substances MDAC are useful include phenobarbital, dapsone, theophylline and carbamazepine.
5.Which of the following is most likely to be effected in the patient with severe chloroquine poisoning, and therefore requires careful monitoring? a.Sodium b.Potassium c.Magnesium d.Chloride e.Glucose
- B – Chloroquine overdose may produce severe hypokalemia which can cause arrhythmias.
1.Which of the following should be administered following an overdose of methotrexate? a.Sodium nitrite b.Leucovorin c.Physostigmine d.Thiamine e.Pralidoxime
1.B - Leucovorin (citrovorum factor, folinic acid): Eliminates the hematopoietic toxicity by supplying the necessary tetrahydrofolate co-factor, the synthesis of which is blocked by methotrexate
2.A medication which is helpful in reducing the renal toxicity of cyclophosphamide is: a.Leucovorin b.Amifostine c.Calcium sulfate d.Mesna e.Mannitol
2.D - Cyclophosphamide-induced incidence and severity of hematuria can be significantly reduced by vigorous hydration, a fractionated dose schedule, and a protector such as Mesna
3.The appropriate initial intervention in extravasation of an infusion of doxorubicin is: a.Apply a heating pad b.Elevate the site c.Stop the infusion d.Apply a constricting band e.Apply topical steroids
3.C - Doxorubicin is a tissue irritant. Should extravasation occur, stop flow of doxorubicin at site immediately.
4.What organ system is most likely to be affected following an overdose of cisplatin? a.Pulmonary b.Cardiovascular c.Hepatic d.Renal e.Nervous
- D - Nephrotoxicity is a dose-limiting toxicity associated with cisplatin therapy. When nephrotoxicity is controlled, nausea and vomiting and neurotoxicity become the dose-limiting toxicities of cisplatin therapy.
5.A bottle of paclitaxel has been dropped on the floor and broken. The most appropriate initial intervention is: a.Neutralize with household bleach b.Contain the spill c.Notify OSHA immediately d.Locate the MSDS e.Open all windows in room
5.B - The mutagenic and carcinogenic potential of many antineoplastic agents is well established and may present a possible health hazard for individuals handling these agents, any spill should be contained quickly.
1.Ingestion of a mouthful of hydrogen peroxide 3% in an adult is most appropriately treated by: a. Gastric lavage b. Dilution with water c. Administration of ipecac d. Administration of activated charcoal e. Administration of antacids
1.B - Three percent hydrogen peroxide is low potential for toxicity and most treatment needed for ingestion would be to dilute with water.
2.Isopropyl alcohol is converted via metabolism to: a.Acetone b.Ethanol c.Formaldehyde d.Oxalic acid e.Methanol
2.A - Isopropyl alcohol is slowly metabolized to acetone. Acetone is metabolized to acetate, formate, and carbon dioxide.
3.The corrosive effects, which may be seen with ingestion of an iodine tincture, may be minimized by: a.Lavage with potassium permanganate b.Administration of n-acetylcysteine c.Administration of activated charcoal d.Induction of emesis e.Having patient eat starchy food
3.E - The presence of food in the stomach inactivates iodine by converting it to iodide which is relatively innocuous. A blue colored emesis indicates the presence of food (starch) in the stomach and the conversion of iodine to iodide.
4.Other than the pine oil itself, what ingredient in most Pine Oil Cleaners could potentially cause toxicity if a toddler consumes a significant amount of the product. a.Isopropyl alcohol b.Ethanol c.Wintergreen d.Ethylene glycol e.Anionic detergents
4.A - Pine oil cleaners may contain isopropyl alcohol 5-10% and if significant ingestion occurs could potentially cause toxicity in a toddler.
5.The combination of household bleach (sodium hypochlorite) and household ammonia will produce: a.Carbon dioxide b.Chloramine gas c.Hydrogen chloride d.Chlorine gas e.Chloroform
5.B - When bleach (sodium hypochlorite) and ammonia are combined, the mixture produces a chloramine gas.
1.Acute isoniazid (TB medication) overdose is most commonly associated with which of the following adverse effects? a.Hypertension b.Metabolic alkalosis c.Respiratory depression d.Seizures e.Hypoglycemia
1.D - Seizures
Other symptoms are not typical of isoniazid overdose
2.Treatment of poisoning due to isoniazid involves which of the following antidotes? a.Phentolamine b.Pyridoxine c.Physostigmine d.Phytonadione e.Pralidoxime
2.B – Pyridoxine is the initial agent of choice for the treatment of INH seizures
3.Which of the following antituberculous drugs is most likely to cause metabolic acidosis when taken in overdose? a.Rifampin b.Pyrazinamide c. Isoniazid d.Ethambutol e.Streptomycin
3C - Isoniazid
None of the others cause acidosis
4.Early management of intoxication due to isoniazid does NOT involve: a.Induction of emesis b.Establishment of an IV line c.Administration of activated charcoal d.Protection of airway e.Assessment of circulatory status
4.A - Emesis not a suggested treatment due to the possible rapid onset of seizures.
5.Which of the following adverse effects is most likely to be seen in the patient treated with rifampin (TB antibiotic)? a.Hepatitis b.Cardiomyopathy c.Exfoliative dermatitis d.Hypocalcemia e.Pulmonary edema
5.A - A possible side effect of chronic therapy. Rifampin can cause transient elevations in hepatic enzymes usually within the first 8 weeks of therapy in 10% to 15% of patients, with less than 1% of the patients demonstrating overt rifampin-induced hepatotoxicity. The occurrence of mortality associated with hepatotoxicity has been reported to be 16 in 500,000 patients receiving rifampin.
1.Which of the following antidotes is most appropriate for the treatment of acute arsenic toxicity? a.Pralidoxime b.BAL c.Atropine d.N-acetylcysteine e.Deferoxamine
1.B - BAL
Other answers are antidotes for other toxins
2.The most appropriate specimen to assist in the assessment of the degree of arsenic poisoning is: a.Whole blood b.Hair and nails c.Stomach contents d.24-hour urine collection e.Feces
2.D - 24-hour urine collection is the best way to check
3.The most common early symptom of acute arsenic poisoning is: a.Pulmonary edema b.Peripheral neuropathy c.Gastroenteritis d.Seizures e.Fever
3.C – Gastritis
Nausea, vomiting and diarrhea are the symptoms most frequently noted with arsenic toxicity.
4.The breath and feces of a person who has been exposed to arsenic compounds may have a characteristic odor, which may aid in diagnosis. This smell is best characterized as: a.Fish b.Garlic c.Ammonia d.Vinegar e.Rotten eggs
- B – Arsenic has often been described as having the smell of garlic
5.Which of the following organ systems are affected by arsenic toxicity? a.Gastrointestinal b.Central nervous system c.Renal d.Hematologic e.All of the above
5.E – Arsenic has toxic effects on all of these systems
1.The ingestion of a ceramic glaze would most likely result in toxicity due to which of the following metals? a.Bismuth b.Antimony c.Lead d.Copper e.Arsenic
1.C – Lead is the most common heavy metal found in ceramic glazes
2.The toxic metal most frequently found in yellow oil paints is: a.Cadmium b.Barium c. Ithium d.Molybdenum e.Strontium
- A – Cadmium yellow oil paint contains high percentages of various cadmium compounds
3.The mother of a child who has ingested a small amount (approximately 1/2 teaspoon) of glitter calls the poison center. The child is asymptomatic. The most appropriate therapy would be: a.Syrup of ipecac b.Gastric lavage c.Activated charcoal d.Whole bowel irrigation e.Observation only
3.E – This child would not be expected to develop toxicity due to this exposure. The glitter would not be absorbed, and should pass uneventfully.
4.Art supplies labeled “CP Non-Toxic”:
a.Are made from only non-toxic materials
b.Do not contain materials in sufficient quantities to harm humans
c.Are tested by the Food and Drug Administration
d.Must be manufactured in the United States
e.Are still likely to be of harm with chronic use
4.B – Products bearing the CP non-toxic label have been certified by the Art & Creative Materials Institute (ACMI) to contain no ingredients in sufficient quantities to be toxic or injurious to humans.
5.An artist who creates metal sculptures with a welding torch is most likely to develop which of the following as a result of his craft? a.Silicosis b.Cardiomyopathy c.Agranulocytosis d.Metal fume fever e.Renal tubular necrosis
- D – Metal fume fever is frequently seen in welders, particularly those who are working with galvanized metal in poorly ventilated areas.
S/S:
Influenza type symptoms - a raised temperature, chills, aches and pains, nausea and dizziness. It is caused by exposure to the fume of certain metals - commonly zinc
1.Which of the following statements concerning hymenoptera envenomation is FALSE:
a.Honey bee stingers are barbed and remain in the victim.
b.Symptoms usually resolve within a few hours.
c.Hypersensitivity reactions to venom allergens are dose-dependent.
d. Those who have had an anaphylactic reaction have approximately a 50% chance of developing the same reaction with subsequent stings.
e.Diphenhydramine and steroids are treatment options for allergic reactions to envenomations.
- C – Hypersensitivity reactions to venom allergens are dose-dependent = FALSE
A single sting may cause an anaphylactic reaction in a sensitive individual.
2.The following are symptoms of an envenomation by a Black Widow spider EXCEPT: a.Abdominal pain b.Muscle fasiculations c.Tachycardia d.Constipation e.Hyptertension
- D – Constipation is not an expected effect following black widow envenomation. Gastrointestinal symptoms that may be seen include nausea, vomiting, excessive salivation, and abdominal pain.
3The most appropriate indication for Black Widow antivenin is:
a.A 75 year-old with chest pain and hypertension
b.A 6 year-old child with leg pain
c.A 35 year-old with tachycardia
d.A 19 year-old with vomiting and paresthesias
e.A 15 year-old with a positive skin test
- A – Antivenin is indicated in the presence of severe systemic symptoms, in high risk patients, and in patients whose pain is not controlled by opioids and muscle relaxants.
4.All of the following are false concerning scorpion envenomation EXCEPT:
a.All United States scorpion stings require an evaluation at an emergency department
b.The Centruroides antivenin is available at any zoo
c.Symptoms are a result of depolarization of nerves and muscles as a consequence of effects in calcium ion channels
d.Rhabdomyolysis is usually a complication of scorpion stings
e.Common stinging scorpions in the US are members of the genera Vejovis, Hadrurus, Androctonus, and Centruroides
- E – The scorpions listed are the most common species found in the US.
Vejovis (Stripedtail Scorpion, Southern Devil), Hadrurus, Androctonus, and Centruroides (bark scorpion)
- Which of the following statements is NOT true concerning ant envenomations:
a.Characteristically one would see wheal, erythema, and edema, as well as considerable pain.
b.Deaths have been due to either allergic reactions or to massive numbers of stings.
c.The fire ant has a necrotizing toxin similar to that of the brown recluse spider.
d.The fire ant stings very quickly producing immediate pain.
e.Ants may have stingers or may bite with their mandibles and spray a toxic substance into the wound created by their jaws.
- D – The fire ant stings very quickly producing immediate pain.
Actually, fire ants sting slowly, and inject their venom over seconds to minutes. Their stings are not usually immediately painful.
1.Which of the following is NOT an expected clinical effect from a toxic ingestion of phenobarbital? a.Coma b.Hypertension c.Nystagmus d.Respiratory arrest e.Skin bullae
1.B – Hypotension, rather than hypertension, would be expected in the presence of a barbiturate overdose.
2.Multiple-dose activated charcoal would be most appropriate in the treatment of an overdose of which of the following barbiturates? a.Butalbital b.Thiopental c.Phenobarbital d.Secobarbital e.Methohexital
2.C – Phenobarbital is a long-acting barbiturate. All of the others are ultra-short or short-acting.
3.Which of the following should NEVER be recommended for treating a toxic ingestion of a barbiturate? a.Hemodialysis b.Alkalinization of the urine c.Hemoperfusion d.Activated charcoal e.Ipecac syrup
- E – Ipecac is contraindicated due to the potential for rapid onset of CNS depression.
4.Which drug has the shortest duration of clinical effects? a.Primidone b.Mephobarbital c.Secobarbital d.Phenobarbital e.Metharbital
4.C – Secobarbital is a short-acting barbiturate. All of the others are long-acting.
1.Which of the following is NOT likely to be contained in a disk battery? a.Barium b.Lithium c.Potassium hydroxide d.Mercury e.Manganese dioxide
1.A – Barium is not a typical component. All of the other choices are commonly found in button batteries.
2.Button batteries lodged in the esophagus require: a.Administration of activated charcoal b.Gastric lavage c.Endoscopic removal d.Whole bowel irrigation e.Induction of emesis
2.C – Batteries lodged in the esophagus require emergent endoscopic removal.
3.Radiographic visualization is required following ingestion of a button battery to ensure that:
a.The battery has not lodged in the esophagus.
b.The battery has not cracked or split.
c.The battery is less than 5 mm in diameter.
d.The battery does not contain any sharp edges.
e.The battery does not contain any radioactive compounds.
3.A – Patients with batteries that have passed beyond the esophagus may be sent home and instructed to watch for GI symptoms or fever.
4.Symptoms to watch for following the ingestion of a button battery include: a.Vomiting b.Bloody stools c.Fever d.Abdominal pain e.All of the above
4.E – Any or all of these symptoms may be associated with complications due to ingestion of a button battery.
5.Following ingestion of a button battery, the patient should be:
a.Hospitalized until the battery has passed entirely through the gastrointestinal tract.
b.Placed on a liquid diet until the battery has passed into the small intestine.
c.Asked to come in for X-ray visualization every 24 hours until passage.
d.Instructed to strain all stools to examine for the presence of the battery.
e.Administered sorbitol every six hours in an attempt to increase transit time.
5.D – Once radiographic visualization has demonstrated that the battery has passed beyond the esophagus, the patient may be managed at home with a normal activity level and diet. Stools should be strained to ensure that the battery has passed.
1.Treatment of a pure benzodiazepine overdose is best accomplished by:
a.Supportive care
b.Hemodialysis
c.Intubation and mechanical ventilation
d.Forced diuresis
e.Immediate administration of flumazenil
1.A - Benzodiazepines are generally of a low order of toxicity. Supportive care is often all that is necessary.
2.Which drug is more likely to cause respiratory arrest following toxic ingestion? a.Clonazepam b.Chlordiazepoxide c.Flunitrazepam d.Diazepam e.Lorazepam
2.C - Generally, benzodiazepines do not cause respiratory arrest unless combined with another depressant such as alcohol. Flunitrazepam, however, has been reported to cause respiratory arrest when taken alone.
3. Which of the following benzodiazepines has the longest half-life? a.Alprazolam b.Diazepam c.Flunitrazepam d.Lorazepam e.Triazolam
3.B - Diazepam.
The parent compound diazepam has a half-life ranging from 20 to 80 hours.
- Which statement about flumazenil is NOT TRUE?
a.It is a specific benzodiazepine receptor antagonist.
b.It may induce acute withdrawal in patients who are addicted to benzodiazepines.
c.It may induce seizures in patients with tricyclic antidepressant overdose.
d.Resedation may occur within 1-2 hours of administration, and repeated dosing is usually required.
e.It is administered intravenously with an initial dose of 2-3 mg.
4.E - The initial dose for a benzodiazepine overdose is 0.2 mg given IV over 30 seconds, with an additional 0.3mg given over 30 seconds if an adequate level of consciousness has not been achieved.
5. The most frequent clinical effect following diazepam overdose is: a.Central nervous system depression b.Respiratory depression c.Hypothermia d.Hypotension e.Bradycardia
5.A - The effects of the benzodiazepines can be attributed to effects on GABA, an inhibitory neurotransmitter in the CNS.
1.Which one of the following beta-blockers is most associated with seizures in toxicity? a.Atenolol b.Naldolol c.Esmolol d.Propanolol e.Sotalol
1.D - From data collected from overdoses, seizures are far more common following overdose with propranolol.
2.Beta-blocker toxicity is not associated with which one of the following? a.Bradycardia b.AV nodal block c.Hyperglycemia d.Hypotension e.CNS depression
2.C - Hypoglycemia may be noted, especially in children or people who are fasting or dieting, or are diabetic.
3.Which one of the following methods of GI decontamination is contraindicated in beta-blocker toxicity? a.Ipecac b.Lavage c.Activated charcoal d.Cathartic e.Hemodialysis
3.A - Emesis would be contraindicated in this situation due to the time to emesis with ipecac and the fact that the beta-blocker drugs can cause CNS depression, cardiovascular abnormalities, and seizures.
4.Which one of the following therapies is not indicated in beta-blocker toxicity? a.Glucagon b.Dopamine c.Atropine d.Digoxin e.Ventricular pacing
4.D - Digoxin, a cardiac glycoside, would definitely not be indicated in the treatment of beta-blocker toxicity. It is used to treat congestive heart failure and in the treatment of atrial fibrillation or flutter. The drug has a very narrow therapeutic index with a high incidence of severe toxicity.
5. In addition to the cardiovascular system, beta blockers may block beta receptors in which of the following organ systems? a.Central nervous system b.Renal c.Hepatic d.Respiratory e.Endocrine
5.D – Beta blockers, particularly those with both beta-1 and beta-2 activity, may cause bronchospasm.
Botulism:
- The best description of botulism is
a.Food borne infection with Clostridium botulinum
b.Sudden onset of spastic paralysis of the limbs but with normal sensation
c.Sudden onset of spastic paralysis of the limbs with paresthesias
d.Neurotoxic flaccid paralysis that always starts with muscles in the face
e.Crying illness that incubates 2 to 3 months
- D - Botulism is a rare but serious neuroparalytic illness characterized by symmetric, descending flaccid paralysis of motor and autonomic nerves, always beginning with the cranial nerves. The etiologic agent is a potent neurotoxin produced from Clostridium botulinum, an anaerobic, spore-forming bacterium.
There are three main kinds of botulism:
- Foodborne botulism follows ingestion of preformed toxin produced in food by C. botulinum. The most frequent source is home-canned foods, prepared in an unsafe manner. Other sources have included homemade salsa, baked potatoes cooked in aluminum foil, cheese sauce, garlic in oil, and traditionally prepared salted or fermented fish in Alaska.
- Wound botulism occurs when C. botulinum spores germinate within wounds. Drug abusers injecting black tar heroin are at increased risk.
- Infant botulism occurs when C. botulinum spores germinate and produce toxin in the gastrointestinal tract of infants
- Classic early symptoms of foodborne botulism include
a. Double vision
b. Vomiting and/or diarrhea
c. Intense headache and stiff neck
d. Constipation
e. Paresthesias in feet and hands
- A - The classic symptoms of botulism include double vision, blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, and muscle weakness. Infants with botulism appear lethargic, feed poorly, are constipated, and have a weak cry and poor muscle tone. If untreated, the illness might progress to cause descending paralysis of respiratory muscles, arms and legs. After several weeks, the paralysis slowly improves. In foodborne botulism, symptoms generally begin 18 to 36 hours after eating a contaminated food, but they can occur as early as 6 hours or as late as 10 days. Botulism can result in death due to respiratory failure. However, in the past 50 years the proportion of patients with botulism who die has fallen from about 50% to 8%. Patients who survive an episode of botulism poisoning may have fatigue and shortness of breath for years after the acute illness
- In addition to intensive supportive care, treatment for severe cases may include
a. Barbiturate coma to protect the CNS
b. Antibiotics active against C. botulinum
c. Antitoxin obtained from the CDC
d. Vaccination against subsequent intoxications
e. Antiseizure medications
- C - Botulinum antitoxin (supplied by CDC) blocks the action of circulating toxin and can prevent progression of illness and shorten symptoms in severe botulism cases if administered early.
- The primary target organ of acute cadmium exposure is the
a. Bone marrow
b. Kidney
c. Liver
d. Lung
e. Bones
- D - Lungs
Most cadmium health risk stems from chronic exposure to environmental contamination, cigarette smoking, and work in industries handling cadmium. However, inhalation of cadmium fumes, such as those that form during welding, is a source of acute toxic exposure. Metal fume fever is a relatively benign occurrence following inhalation of metal oxide fumes from high heat work with various metals, especially zinc. However, cadmium fumes can cause a serious pneumonitis in addition to metal fume fever. Anyone working galvanized metal (zinc coated) may have some risk of cadmium exposure also since cadmium frequently contaminates zinc ore.
- The primary target organ of chronic cadmium exposure is the
a. Bone marrow
b. Kidney
c. Liver
d. Lung
e. Bones
- B - The target organ of chronic exposure is the kidney. Cadmium is bound to a protein called metallothionein in the renal tubule cells; its half life of elimination is about 10 years. Since cadmium exposure is ongoing, cadmium bioaccumulates within the kidney during a lifetime. When the capacity of the tubule cells is exceeded, free cadmium is released and damages the cell. Itai itai (“ouch ouch” ) is an end stage disease in Japanese who ate rice grown in grossly contaminated paddies. The “ouch” is bone pain, that occurs not from primary pathology in the bones, but from renal osteomalacia - thin weak bones prone to spontaneous fracture because of impaired vitamin D and calcium management in sick kidneys.
- The primary target organ of chronic cadmium exposure is the
a. Bone marrow
b. Kidney
c. Liver
d. Lung
e. Bones
- B - The target organ of chronic exposure is the kidney. Cadmium is bound to a protein called metallothionein in the renal tubule cells; its half life of elimination is about 10 years. Since cadmium exposure is ongoing, cadmium bioaccumulates within the kidney during a lifetime. When the capacity of the tubule cells is exceeded, free cadmium is released and damages the cell. Itai itai (“ouch ouch” ) is an end stage disease in Japanese who ate rice grown in grossly contaminated paddies. The “ouch” is bone pain, that occurs not from primary pathology in the bones, but from renal osteomalacia - thin weak bones prone to spontaneous fracture because of impaired vitamin D and calcium management in sick kidneys.
- Chronic cadmium exposure is best assessed by
a. Analysis of tissue biopsy for cadmium
b. Blood levels of cadmium
c. Cadmium urine levels
d. Cadmium urine levels before and after chelation
e. Urinary albumin excretion
- C - As for most metals, recent exposure can be assessed by blood levels, but total body burden reflecting chronic exposure is best measured in the urine. Chelation challenge is not useful, and may be harmful if it mobilizes free cadmium into renal cells. Biomonitoring for the earliest signs of cadmium damage to the kidney is done in chronically exposed workers, but the protein investigated are small tubular “microproteins” rather than albumin. Albumin is a large protein that marks of glomerular damage.
- What best describes a metalloid?
a. Element heavier than water that is liquid at room temperature.
b. Elements with properties of both metals and non-metals.
c. Inseparable mixture of 2 or more metals.
d. Chemically altered metal with plastic-like properties.
e. Elements that cannot conduct electricity.
- B - Metalloids are the elements that have ionization and binding properties that are in-between true metals and non-metals in the periodic table. Metalloids have binding properties of both metals and nonmetals. Metals tend to lose electrons (oxidized). Nonmetals tend to gain electrons (reduced). Metalloids can be either oxidized or reduced in chemical compounds. They can be identified on the periodic table by highlighting in the shape of a stair-step.
- Which of the following is a metalloid?
a. Mercury
b. Cadmium
c. Arsenic
d. Radium
e. Aluminum
- C - The metalloids are boron, silicon, germanium, arsenic, antimony, tellerium, and polonium. Toxicologically the most significant metalloid is arsenic.
- Metalloids are particularly found in:
a. The semi-conductor industry
b. Space program vehicles
c. Magnetic/antimagnetic ceramics
d. Thermometers and thermistors
e. Antibacterial soaps
- A - True metals are good conductors of heat and electricity. Metalloids can conduct heat and electricity only under certain circumstances. Thus they are called “semi-conductors” and they are very useful in computer electronics.
1.Caffeine is pharmacologically and toxicologically similar to what medication? a.Cyclobenzaprine b.Theophylline c.Amitriptylline d.Carbamazepine e.Phencyclidine
1.B - Caffeine is pharmacologically and toxicologically similar to theophylline.
2.Which of the following symptoms would not be associated with a caffeine overdose? a.Tachycardia b.Vomiting c.Seizures d.Restlessness e.Lethargy
2.E - Insomnia, anxiety, restlessness and tremor are common following mild to moderate overdoses. Tinnitus, delirium, headache, low-grade fever, photophobia, and seizures are reported with severe intoxication.
3.What two fluid-electrolyte imbalances occur following a caffeine overdose? a.Hypokalemia and hypernatremia b.Hyperkalemia and hypernatremia c.Hypokalemia and hyponatremia d.Hyperkalemia and hyponatremia e.None of the above
3.C – Hypokalemia and hyponatremia can be caused by caffeine toxicity
4.Which of the following products does not contain caffeine? a.Coffee b.Chocolate milk c.Eggs d.Iced tea e.Jolt cola
4.C - Eggs do not contain any type of caffeine, unless it would be added to them in the process of cooking or baking.
5.Which of the following statements regarding caffeine is true?
a.Caffeine may inhibit theophylline metabolism resulting in an increase in the renal clearance of theophylline.
b.Caffeine constricts the smooth muscle of the bronchi.
c.Caffeine acts on the stomach to decrease gastric acid and pepsin secretion.
d.At the cortical level, caffeine temporarily allays the sensations of drowsiness and fatigue, enhances flow of thought, and permits a greater intellectual effort.
e.Caffeine may induce vasoconstriction of the coronary arteries and vasodilation of the cerebral arteries together with a slight net peripheral vasoconstriction.
5.D - Caffeine exerts its stimulatory effect directly on the cerebral cortex, medulla oblongata, and spinal cord. At the cortical level, caffeine temporarily allays the sensations of drowsiness and fatigue, enhances flow of thought, and permits a greater intellectual effort. At the medullary level, caffeine acts chiefly as a respiratory stimulant.
1.A patient arrives in the emergency department after ingestion of 50 diltiazem (Cardizem CD®) 300 mg tablets. The patient is alert with a heart rate of 45 beats per minute and a blood pressure of 90/p mmHg. A decision to administer calcium is made. Which calcium salt is the preferred drug for intravenous route? a.Calcium chloride b.Calcium gluconate c.Calcium carbonate d.Calcium phosphate e.None of the above
1.A - Calcium chloride is thought to produce more predictable increases in extracellular ionized calcium and a greater positive inotropic response. It provides three times more elemental calcium (272 milligrams; 13.6 milliequivalents) than calcium gluconate (90 milligrams; 4.5 milliequivalents) in their commercially available 1 gram ampules.
2.Which treatment is not considered useful in the treatment of calcium channel antagonist poisoning?
a.Calcium
b.Glucagon
c.Atropine
d.Hemodialysis
e.Installation of an intraaortic balloon pump
2.D - In general, the large volumes of distribution and high protein binding of all calcium channel blocking agents would suggest hemodialysis or hemoperfusion would have limited usefulness in removal of significant quantities of these drugs.
3.Which calcium channel antagonist would be expected to result in the most negative inotropic effects after overdose? a.Nimodipine b.Verapamil c.Diltiazem d.Nifedipine e.Amlodipine
3.B - Hypotension with systolic blood pressures less than 100 mmHg is common following significant overdose with all agents, but particularly with VERAPAMIL; syncopal episodes secondary to impaired perfusion may occur.
4.A 2 year old child is found playing with a bottle of his grandfather’s verapamil (Calan SR®) 240 mg tablets. After a pill count, all but one is accounted for. An appropriate disposition would include?
a.Watch the child at home
b.Watch the child at home and administer syrup of ipecac
c.Watch the child in emergency care for 2 hours
d.Watch the child in emergency care for a minimum 8 hours
e.Watch the child in intensive care for 48 hours
4.D - All patients with a history of calcium antagonist ingestion should have a baseline electrocardiogram and be monitored for a minimum of 8 hours. Consider longer monitoring/observation for patients with a history of ingesting sustained-release products.
5.The following constellation of vital sign abnormalities would be consistent with calcium channel blocker poisoning except? a.Decreased heart rate b.Decreased blood pressure c.Normal temperature d.Increased heart rate e.Normal respiratory rate
5.E - Noncardiogenic pulmonary edema has been reported following DILTIAZEM and VERAPAMIL overdose, which could cause respiratory symptoms. Kussmaul respiration was described 2 hours after ingestion of 2.4 grams of VERAPAMIL.
1.Which mothball would you not expect to be radiopaque? a.Camphor b.Naphthalene c.Paradichlorobenzene d.Oxybenzamine e.All are radiopaque
1.A - Camphor is a translucent crystalline mass, blocks, or powdery masses, with characteristic penetrating aromatic odor and pungent aromatic taste. It is not radiopaque.
2.Three, 3 year old males are found playing with an empty box of mothballs containing naphthalene. Assuming they all were exposed to equal quantities, which characteristics of the child may place them at greater risk for toxicity? a.They are at equal risk b.Asthma history c.Depressed G6PD activity d.Previous exposure history e.Their lean body weight
2.C - Infants and patients with G-6-PD deficiency, sickle cell anemia, or sickle trait are more likely to develop hemolysis and methemoglobinemia.
3.A 20 year old female ingests 3 paradichlorobenzene mothballs in a suicide attempt. Toxicity expected would include: a.Seizures and respiratory depression b.Minimal toxicity expected c.Hepatic failure d.Renal failure e.Pulmonary failure
- B - Individuals who are exposed to higher concentrations of paradichlorobenzene may show weakness, dizziness, and weight loss. Vomiting may occur. Greater than 3 mothballs should be considered higher concentrations.
Refer:
Camphor or Unknown >1 mothball
Naphthalene or Para-dichlorobenzene > 5
4.A child is found seizing in the attic of an old house. A "mothball" odor is detected. Identify the mothball and associated "antidote" for the seizure. a.Paradichlorobenzene: benzodiazepines b.Camphor: benzodiazepines c.Naphthalene: pyridoxine d.Paradichlorobenzene: pyridoxine e.Camphor: pyridoxine
4.B - Camphor causes seizures and the first line of treatment would be benzodiazepines.
5.Monitoring after naphthalene exposures should include the following:
a.Urine dipstick for hemoglobin, peripheral blood smear
b.Ammonia levels
c.SMA-7, LFT’s
d.PT monitoring and LFT’s
e.Serum osmolarity
5.A - Naphthalene can cause hemolysis and therefore patients should be monitored for hemoglobin in the urine after significant ingestions.
1.Which organ is NOT considered a target for carbon monoxide poisoning? a.The brain b.The liver c.The blood d.The heart e.They all are directly targeted
1.B - Primary manifestations of carbon monoxide toxicity develop in the organ systems most dependent on oxygen utilization: the central nervous system and the myocardium.
2.Which toxin generates carbon monoxide endogenously?
a.Carbon monoxide released from car exhaust
b.Methane
c.Propane
d.Methylene chloride
e.Butane
2.D - Methylene chloride is metabolized in part to carbon monoxide and may cause elevations in carboxyhemoglobin (COHb), rarely as high as 50% in severe exposures
3.Which of the following is NOT considered a source of exposure to carbon monoxide? a.Paint stripper b.Ice rink Zamboni machines c.Car exhaust d.A gas leak e.Charcoal briquettes
3.D - A simple gas leak, without incomplete combustion would not cause carbon monoxide poisoning. Would be a simple asphyxiant.
4.A 20 year old male is found unconscious after exposure to carbon monoxide through car exhaust. The first management employed should include: a.Hyperbaric oxygen b.100% oxygen c.Removal from exposure d.Glucose e.70%/30% mixture of oxygen
4.C - Need to move person to fresh air prior to attempting any other means of revival. Removing the source would decrease chances of potential toxicity.
1.Which of the following toxins are corrosive? a.Hydrogen peroxide b.Acids c.Bases d.Phenol e.All of the above
1.E - Some substances may be irritating or corrosive depending on the concentration, molarity, and other factors. In general, serious esophageal injury is associated with ingestion of products with a pH of 11.5 or higher. Examples of these are hydrogen peroxide, acids, alkalis, and phenols.
2.The mechanism of burn seen after alkaline exposure is: a.Coagulation necrosis b.Liquefaction necrosis c.Irritant d.Lipid depleting e.Fatty deposition
2.B - Alkaline corrosives cause liquefaction necrosis, allowing deep penetration into mucosal tissue as cells are destroyed.
3.A 56 year old biomedical engineer gets splashed in the dorsal aspect of his arm with 95% phenol solution. Which of the following choices would be considered appropriate management? a.Apply vitamin E b.Do nothing; it is not corrosive c.Rinse with PEG solution d.Rinse with acetic acid e.Rinse with milk
3.C - Decontamination of a dermal exposure may be accomplished with polyethylene glycol 300 or 400, isopropyl alcohol, or copious amounts of water. Decontamination personnel should take precautions.
4.In which occupation would you see use of silver nitrate? a.Tire industry b.Shoe makers c.Airplane builders d.Photographic filmmaking e.None of the above
4.D - Silver nitrate is used in the manufacture of silver chloride, photographic sensitive materials, photographic plating, mirrors, catalysts, and pharmaceuticals. It may also be used in photographic dark rooms
5.A 45 year old male is splashed with 100% hydrofluoric acid while at work. A specific antidote useful in this situation is: a.Calcium for hypocalcemia b.Calcium for hyperphosphatemia c.Phosphates for hypercalcemia d.Phosphates for hypophosphatemia e.None, there is no special therapy
5.A - Calcium gluconate or calcium carbonate gel applied topically to the affected area has been associated with relief of pain at the site of exposure. Systemic toxicity or severe tissue damage is unlikely to occur with small surface area exposures to dilute solutions. Correct known or suspected hypocalcemia with calcium.
1.A 21 year old male is brought into the emergency department after illicit drug use. He is agitated with vital signs including a heart rate of 130 beats per minute and a blood pressure of 140/90 mmHg. His temperature is 104 F and his respiratory rate is 26 breaths per minute. His pupils are dilated and he is diaphoretic. The most likely toxin to be associated with his findings is: a.Cocaine b.Phencyclidine c.LSD d.Psilocybin e.Marijuana
1.A - The signs and symptoms of cocaine intoxication are related primarily to its sympathomimetic and local anesthetic effects. Symptoms commonly noted include agitation, tachycardia, hypertension, mydriasis and diaphoresis. Chest pain with or without evidence of myocardial infarction may be noted.
2.A plane from South America arrives with one of its passengers complaining of severe abdominal pain. Upon further inspection, the passenger is found to have several wrapped substances in his gastrointestinal tract (visualized by abdominal radiograph). This patient is transferred to a local HCF. What recommendations for treatment would be the best?
a.A dose of charcoal and then begin whole bowel irrigation
b.Lavage and charcoal
c.Surgical removal of the packets
d.Ipecac
e.None of the above
2.A - Whole Bowel Irrigation (WBI) may be a relatively safe and effective means of rapid decontamination for the asymptomatic body packer. Activated charcoal should be administered prior to beginning whole bowel irrigation as polyethylene glycol (PEG) solution decreased the ability of charcoal to adsorb charcoal in vitro.
3.All of the following life-threatening signs and symptoms have been attributed to cocaine except: a. Bowel infarction b. Hypothermia c. Hypertensive crisis d. Cardiac arrest e. Ventricular tachycardia
3.B - HYPERTHERMIA is common and life-threatening and may be due to increased muscular activity, vasoconstriction, and perhaps a direct effect on the hypothalamus. Sinus tachycardia, atrial arrhythmias, PVCs, bigeminy, and ventricular fibrillation have been reported.
4.All of the following would be considered a treatment for cocaine poisoning except: a.Diazepam b.Ice cooling c.Intravenous fluids d.Phenobarbital e.Propanolol
4.E - Propranolol is NOT a SPECIFIC antidote for cocaine overdose. Propranolol has been associated with increased blood pressure in the setting of cocaine overdose, presumably due to unopposed alpha adrenergic stimulation.
5.Which of the following routes can be used for cocaine abuse? a.Intranasal b.Oral c.Intravaginal d.Intravenous e.All of the above
5.E - ALL ROUTES OF ADMINISTRATION (intranasal, oral, rectal, intravenous, inhaled, and intravaginal) have been associated with the effects described below. There may be no difference in cocaine’s clinical toxicity whether smoked or injected intravenously.
- The mechanism of action of cyanide is
a. Simple asphyxiation
b. Impaired oxygen uptake
c. Impaired oxygen delivery
d. Impaired aerobic energy production
e. inhibition of neurotransmitter release
- D - Cyanide is considered a chemical asphyxiant. Oxygen uptake through the lungs, transport on hemoglobin and delivery to tissues are normal. However, cyanide binds to and renders impotent the iron-containing cytochome protein in the metabolizing tissues such that it cannot hold oxygen and use it in aerobic energy production. Symptoms occur first in the CNS and cardiovascular systems, which are the most sensitive to loss of cellular energy.
- The management of cyanide poisoning includes all of the following EXCEPT:
a. Oxygen
b. Sodium nitrite
c. Sodium thiosulfate
d. Bedrest
e. Methylene blue
2.E - Methylene Blue
Supplemental oxygen remains the most important therapy, and is always included in treatment regimens. In severe cases unresponsive to usual antidotal measures, hyperbaric oxygen has been suggested. Nitrite, either inhaled as amyl nitrite ampules and/or intravenous injection as sodium nitrite is given. In theory, the methemoglobin produced by nitrite is better able to attract cyanide off the tissue cytochromes which restores their function. Sodium thiosulfate is then given to act as a substrate for the enzyme rhodenese, which accelerates the metabolism of cyanide to the less toxic thiocyanide which is then excreted. The patient should always be kept calm, warm, and at rest, preferably lying down, to minimize oxygen demand. Furthermore, antidotal nitrite may precipitously drop blood pressure, so the patient should be recumbent.
*Methylene blue would be contraindicated since the reversal of methemoglobin would release the cyanide back to bind upon the cytochromes.
- Sources of cyanide exposure include all of the following EXCEPT:
a. Building fires involving plastics
b. Charred meat
c. Metabolism of organic nitriles such as acetonitrile
d. Bitter almonds and seeds within fruit pitts
e. Cigarette smoke
3.B - Any material containing nitrogen can produce hydrogen cyanide under fire conditions including common household synthetics such as plastics. Organic nitriles are metabolized to cyanide; symptoms compatible with cyanide toxicity may evolve several hours after exposure. Bitter almond (not to be confused with the sweet almond which is edible) and the seeds of pitted fruits of the Prunus species such as apricots and cherries, contain cyanogenic glycosides, which are also metabolized in vivo to free cyanide. Cigarette smoking is the single largest source of cyanide exposure outside of cyanide-using industries. Charring meat produces Poly Aromatic Hydrocarbons (PAH) and nitrosamines which are potentially carcinogenic.
- The mechanism of action of hydrogen sulfide is
a. Simple asphyxiation
b. Impaired oxygen uptake
c. Impaired oxygen delivery
d. Cytotoxic lung injury
e. Similar to cyanide
4.E - Similar to cyanide
Hydrogen sulfide is a highly toxic gas that is able to react with many proteins containing disulfide bonds. The critical effect is interference with cytochrome oxidase in the tissues, resulting in inhibition of cellular utilization of oxygen and impaired energy production. H2S is a more potent cytochrome oxidase inhibitor than cyanide.
- Risk of hydrogen sulfide exposure is present in:
a. Anaerobic decay of organic matter
b. Use of natural gas
c. Limestone and granite fields
d. Wells dug in coal and oil rich areas
e. Dissolving sulfuric acid in hydrocarbon solvent
5.D – Wells dug in coal and oil rich areas.
H2S may be found in environments where the decay of sulfur - containing organic material occurs by anaerobic or sulfur - producing bacteria. Adequate aeration of sewage, manure pits and other risky collections of organic material prevents production of H2S. Reported risk situations also include sewers and sewage treatment plants, mines, sulfur springs, manure stockpiles, the holds of fishing ships, and wetland construction sites.
H2S is the primary chemical hazard of natural gas production as natural gas, before it is cleaned, may contain several percent hydrogen sulfide (“sour”gas). Natural gas delivered for use as a fuel is not a source of H2S and in fact, another sulfur compound is added as a stenchant to make people aware of an escape of the otherwise odorless gas.
Areas with deposits of organic fuels (peat, coal, gas, oil) are usually found in rocky substrates of sandstone or shale. Subsoil penetration in such areas, as by wells, always carries a risk of H2S exposure.
- The leading toxic cause of sudden death in the workplace is:
a. Cyanide
b. Carbon monoxide
c. Hydrogen sulfide
d. Nitrogen
e. Chlorine
6.C – Hydrogen sulfide.
According to NIOSH, sudden death from acute overexposure to a toxin in the workplace is most often due to hydrogen sulfide. In the petroleum industry alone, more than 1400 significant exposures with nine fatalities occur annually.
- Treatment of hydrogen sulfide poisoning does NOT include:
a. Oxygen
b. Amyl and/or sodium nitrite
c. Sodium thiosulfate
d. Induced methemoglobin formation
7.C - Sodium thiosulfate.
Oxygen is the most important treatment measure after removal from exposure. Administration of a nitrite, either inhaled as amyl nitrite or intravenously as sodium nitrite, appears to release hydrogen sulfide from tissue cytochrome and restore aerobic cellular energy production. Whether the methemoglobin induced by nitrite is partially responsible for the therapeutic effect is controversial. Because thiosulfate is administered as a substrate for an enzyme metabolizing cyanide, it does not have any use in a poisoning by hydrogen sulfide. Keeping the patient, warm, calm, and at rest to minimize oxygen demand is proper management of impaired energy production states no matter their etiology.
Cyclic Antidepressants:
- Sodium channel function in cardiac muscle is best observed in which part of the EKG?
a.The P wave (atrial conduction)
b.The PR interval (atrial-ventricular conduction)
c.The QRS wave (ventricular depolariztion)
d.The Q wave (ventricular repolarization)
e.All of the waves
- C - The QRS wave (ventricular depolariztion).
The sodium channels embedded in neural membranes are closed and prevent sodium from entering the interior of the cell in the resting state. When a change in membrane voltage occurs, the sodium channels suddenly open, allowing an influx of sodium inside the cell. This rapid shift in sodium ions depolarizes the cell membrane and the action potential is propagated down the nerve. Sodium channels then close again. The Sodium-Potassium ATPase punp uses cellular energy to restore the membrane potential back to normal by pumping the sodium back outside the cell to wait for another voltage signal to the sodium channels.
The EKG records the initiation and spread of the depolarization wave and subsequent repolarization throughout the heart. The P wave represents depolarization of the atria; the PR interval records the delay in transmission of the action potential from the atria through the AV node. The QRS wave records the spread of depolarization through the ventricles, and the Q wave records repolarization of the ventricles. The QT interval measures the ventricular phase of the cardiac cycle- both depolarization and repolarization.
Because of the mass of the ventricles compared to the other cardiac tissue, and their specialized super-fast conduction system (Bundle of His, and its right and left bundles) the best part of the EKG to show the function of the sodium channel is the QRS wave.
- Which anticonvulsant should be avoided in treatment of seizures in cyclic antidepressant poisoning?
a. Pentobarbital
b. Fosphenytoin
c. Diazepam
d. Lorazepam
e. Fentanyl
- B - Since phenytoin, and its parenteral form phosphenytoin, have an anti-seizure effect by interfering with action of the sodium channel, it is probably best to avoid this in poisonings already complicated by blockade of the sodium channels such as occurs in cyclic antidepressant poisoning.
- A depressed patient ingested all of his medication. Although he was awake and alert on arrival to the emergency room, he suddenly lapsed into coma, and had a brief grand mal seizure. The most likely agent of intoxication is:
a. Valproic acid
b. Bupropion
c. Sertraline
d. Amitryptyline
e. Alprazolam
- D - Amitryptyline.
Sudden onset of CNS depression with rapid progression into coma is a classic presentation of cyclic antidepressant poisoning. Both seizures and arrhythmia are possible features. If sodium channel block is significant, the QRS wave on the EKG will widen. Wide QRS is a marker for increased risk of seizure as well as arrhythmia. However, therapy with sodium bicarbonate will reduce only the risk of arrhythmia; it does not reduce the risk of seizure or lighten the coma.
1.Sibutramine (Meridia) is a drug used in the treatment of obesity. Sibutramine is a(n):
a.Amphetamine and antidepressant
b.Anticholinergic drug
c.Bulk-forming laxative
d.Local anesthestic
e.Nonamphetamine drug and antidepressant
1.E – Sibutramine is a nonamphetamine appetite suppressant that is also known to block the reuptake of norepinephrine, serotonin and some dopamine at the neuron.
- A 22 year old woman with a history of obesity and depression is brought to the emergency department by her boyfriend approximately five hours after ingesting 30 tablets of diethylpropion hydrochloride 75mg (Tenuate Dospan®) in an attempt to harm herself. In the emergency department she is crying, agitated, moving continuously and verbalizing a desire to die.
Vitals: 182/105, 131, 28, 38.2
Labs: Na 141, K 3, Cl 106, CO2 17, BUN 12, Cr. 0.6, Glu 120, CK 1243. Urine + hemoglobin.
Which of the following intervention may be useful in managing this patient? a.Intravenous benzodiazepine b.Hemodialysis c. Ipecac syrup administration d. Restrict intravenous fluids e. Urinary acidification
- A – Intravenous benzodiazepine.
Diethylpropion hydrochloride is a drug that has pharmacological properties similar to amphetamines. This patient is exhibiting signs of toxicity (fever, tachycardia, hypertension, fever, rhabdomyolysis, agitation, acidosis and hypokalemia). Intravenous benzodiazepines would be useful in decrease movement and thereby decreasing heart rate, blood pressure, fever, and muscle breakdown.
3.Overdose of orlistat (Xenical) may cause: a.Coma b.Decrease in platelet count c.Diarrhea d.Prolongation of the QRS interval e.Seizures
3.C - Diarrhea
Orlist is poorly absorbed across the gastrointestinal (GI) tract whereas, GI effects may occur, systemic toxicity is not expected.
4.An 18-year-old woman ingested about 90 tabs of an over-the-counter diet aid containing ma huang in suicide attempt about four hours ago. A toxic effect that may occur with this ingestion includes: a.Hypoglycemia b.Hypokalemia c.Hypothermia d.Sedation e.Vasodilation
4.B – Hypokalemia
Ma huang is a source of ephedra. Toxic effects of oral sympathomimetics may include hyperglycemia, hyperthermia, hypokalemia, agitation, and vasoconstriction.
5.A 13-year-old girl is brought to the emergency department by her family for “flu” symptoms. Physical examination reveals a malnourished female with vomiting and diarrhea. Hypotonia, dehydration and absence of subcutaneous fat are noted. Patient weight is 30.9kg (68 pounds). EKG findings include prolongation of the QTC interval, sinus tachycardia with premature ventricular contractions.
Vitals: 92/50, 12, 16, 36.0.
Labs: Na 138, K 3.0, Cl 90, CO2 20, BUN 29, Cr. 1.3.
Which of the following most likely explains this patient’s clinical presentation? a.Chromium picolinate use b.Guarana abuse c.Ipecac syrup abuse d.Ma huang use e.Orlistat use
5.C - Ipecac syrup abuse.
This patient has evidence of Ipecac syrup abuse (hypotonia, hypochloremia, hypokalemia, tachycardia with QTC prolongation, PVCs, as well as dehydration). Orlistat has limited absorption across the gastrointestinal tract; it would not cause significant systemic toxicity. Guarana, a source of caffeine, and ma huang, a source of ephedra, are unlikely etiologies due to the lack of stimulant effects.
6.Which of the following may be useful in managing the patient with chronic use of supra-therapeutic doses of chromium picolinate for weight loss?
a.Consider hemodialysis to remove chromium
b.Monitor liver enzymes and renal function
c.Supplement diet daily with vitamin C 5000mg
d.Collect hair sample for analysis
e.Consider endoscopy for esophageal necrosis
6.B – Monitor liver enzymes and renal function.
Chronic supra-therapeutic doses of chromium picolinate has resulted in elevated liver enzymes and renal impairment. Hemodialysis does not effectively remove chromium picolinate. This dietary supplement may cause mild gastrointestinal distress, however, corrosive effects are not expected.
1.Cardiac glycosides are found in all of the following plants except: a.Oleander b.Foxglove c.Lily of the valley d.Water hemlock e.Red squill
1.D - water hemlock is a stimulant
