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Poison/Toxicology > Exam 2 > Flashcards

Exam 2 Flashcards

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1
Q

Adult lead level: severe

A
  • Encephalopathy, wrist/foot drop, pallor/anemia, abdominal colic, nephropathy
  • > 100 mcg/dL
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2
Q

Adult lead level: moderate

A
  • HA, weakness, peripheral neuropathy, abdominal pain, constipation
  • 70-100 mcg/dL
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3
Q

Adult lead level: mild

A
  • Fatigue, confusion, somnolence, HTN, kidney impairment
  • <70 mcg/dL
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4
Q

Lead toxicity diagnosis

A
  • Environmental, occupational, recreational exposure, PICA
  • Blood Lead Level (BLL) = gold standard
  • CBC, CMP
  • X-rays can spot “lead lines” on bones
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5
Q

Lead toxicity treatment steps

A
  1. GI decontamination: WBI
  2. Chelation: start ASAP
  3. BZD if seizures
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6
Q

Lead toxicity treatment: overt encephalopathy

A

Dimercaprol & Calcium disodium EDTA

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7
Q

Lead toxicity tx: Symptoms suggestive of encephalopathy or >100 in adults, >69 in peds

A

Dimercaprol & Calcium disodium EDTA

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8
Q

Lead toxicity tx: mild symptoms or 70-100

A

Succimer

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9
Q

Lead toxicity tx: asymptomatic or <70 in adults or 45-69 in peds

A

Treat peds with succimer vs X in adults

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10
Q

Arsenic acute toxicity s/s

A
  • GI: N/V/D w/i mins to hrs
  • CV: tachy, HoTN, QTc prolongation
  • Encephalopathy: seizure, delirium, coma
  • Dermatologic: “mees lines”
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11
Q

Arsenic Chronic toxicity s/s

A
  • Neuropathy, malignancy, DM
  • Dermatologic: carcinomas, hyperpigmentation
  • Hepatic portal fibrosis
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12
Q

Arsenic toxicity diagnosis

A

24-hr urine level (gold standard)
- [Arsenic] >50
- Creatinine >100
- Total Arsenic >100

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13
Q

Arsenic toxicity tx: including mild vs severe

A
  1. GI decontamination: charcoal, WBI only if visible radiopacities
  2. Chelation:
    - Mild (N/V): succimer
    - Severe (encephalopathy/seizure): dimercaprol (BAL) IM
  3. Acute encephalopathy seizures: BZD
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14
Q

Mercury toxicity s/s: elemental

A

Tremor

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15
Q

Mercury toxicity s/s: inorganic

A

Tremor, erethism, GI ulcer, acute tubular necrosis (ATN), acrodynia

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16
Q

Mercury toxicity s/s: organic

A

Tremor, paresthesia, ataxia, dysarthria, tunnel vision, GI distress, AKI

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17
Q

Mercury toxicity diagnosis

A

24-hr concentration
- Normal: serum <10, urine <20
- Severe: serum >35, urine >150

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18
Q

Mercury toxicity tx

A
  1. WBI for inorganic
  2. Chelation:
    - Inorganic: Dimercaprol BAL
    - Inorganic or organic (able to take PO): succimer
    - 3rd line: d-penicillamine
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19
Q

Iron toxicity stage I s/s

A

0-6 hrs
- GI: N/V/D, abdominal pain
- Potential to recover or exhibit systemic toxicity
- Absence of vomiting in first 6 hrs decrease likelihood of toxicity

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20
Q

Iron toxicity s/s: stage II

A

6-24 hrs - Latent stage
- Resolution of GI
- Progressive systemic deterioration secondary to volume loss & worsening metabolic acidosis, lethargy

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21
Q

Iron toxicity s/s: stage III

A

24-48 hrs
- Shock, lactic acidosis
- Coagulopathy -> bleeding -> hypovolemia -> increased aPTT
- Renal failure, cardiomyopathy, elevated LFTs, encephalopathy

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22
Q

Iron toxicity s/s: stage IV

A

2-5 days
- Hepatotoxicity, lipid peroxidation
- Increased aminotransferase -> acute fulminant hepatic failure

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23
Q

Iron toxicity s/s: Stage V

A

4-6 weeks
- Sequela: gastric outlet obstruction due to corrosion of the pyloric mucosa

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24
Q

Iron toxicity diagnosis based on serum [ ] & clinical manifestation: 300-500 mcg/dL

A
  • Significant GI symptoms
  • Modest systemic toxicity
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25
Iron toxicity diagnosis based on serum [ ] & clinical manifestation: 500-1000 mcg/dL
Metabolic acidosis, **shock**
26
Iron toxicity diagnosis based on serum [ ] & clinical manifestation: >1000 mcg/dL
Organ failure, **mortality**
27
Iron toxicity management: **do not** give
Ipecac syrup, AC, cathartics, oral sodium bicarbonate, phosphosoda
28
Iron toxicity management: WBI if...
Radiopacities present
29
Iron toxicity management: **chelating agents** indicated if...
Repeatedly V, HoTN, lethargic, acidotic, peak iron level >500 mcg/dL
30
Chelating agent (Antidote) for iron toxicity
Deferoxamine, (Vin Rose Urine- with deferoxamine)
31
OTC_Anticholinergic management
BZD, Physostigmine slow IV push
32
OTC_Loperamide (Imodium): symptoms
**QRS, QTc prolongation**, mono- & polymorphic (TdP) ventricular arrhythmias
33
CBD gummies toxicity symptoms
CNS depression, excitation, children = resp depression, seizures
34
Dinitrophenol (DNP) toxicity symptoms, management
- **Hyperthermia, agranulocytosis**, tachycardia/pnea, maculopapular erythematous skin eruptions - Aggressive supportive care: cooloing, BZD
35
Pong Pong Seeds toxicity: symptoms, management
- Continues vomiting - One dose AC, Digoxin-specific antibodies (Fab)
36
Dextromethorphan (Triple C's, Robitussin) toxicity symptoms, management
- Confused, hallucinating, behavioral & dissociative effects, false(+) urine test for PCP - Supportive care: BZD
37
Neptune's Fix (Tianeptine) toxicity: symptoms, management
- Unresponsive, AMS, naloxone-responsive resp depression, opioid-like withdrawal upon cessation of chronic use - Wean down detoxification, buprenorphine & clonidine
38
Hypoglycemic diagnosis: BG level, symptoms
- <60 mg/dL - **Decreased level of alertness, dizziness, confusion, seizures, tachy, bizarre behavior**, tremors, hypothermia, diaphoresis, pallor, N
39
Hypoglycemic toxicity absorption prevention
1. AC: w/i 2 hrs 2. WBI: not generally recommended
40
Hypoglycemic treatment of symptomatic
1. "Rule of 15" - glucose PO 2. Dextrose 0.5-1 g/kg IV 3. Glucagon IM
41
Hypoglycemic Sulfonylureas toxicity: causing agents, MoA, management, prophylaxis
- 2nd gen: Glimepiride, Glipizide, Glyburide - Sulfonylureas are **Insulin secretagogues** (increase insulin) - **Prolonged & delayed** onset of hypoglycemia, **rebound hypoglycemia** - ABCDs, AC, octreotide for maintaining euglycemia - Not recommended
42
Hypoglycemic toxicity- Octreotide: indication, formulation
- Inhibit release of insulin, glucagon, secretin, motilin -> maintain euglycemia - Single dose SQ/IV
43
Hypoglycemia- Metformin toxicity: worsened by___, symptoms, treatment
- Metabolic acidosis - N/V, myalgia, malaise, blindness, hypothermia, resp insufficiency, HoTN - ABCDs, vasopressors, fluids, **Extracorporeal Treatment (ECTR: intermittent hemodialysis)**
44
Hypoglycemia- ECTR: recommendation including lactate, pH, comorbid conditions
1. [Lactate] >20 mmol/L (>15 suggested) 2. pH =<7.1 (=<7.0 suggested) 3. Failure of standard supportive care 4. Comorbid conditions: shock, liver failure decreased level of consciousness
45
Hypoglycemia- Insulin toxicity: toxic MoA, management
- Disproportionate **depot effect** -> delayed onset hypoglycemia - Initial bolus D50W, D10W -> maintain euglycemia with D5W, D10W
46
Maintaining euglycemia target BG
100-150 mg/dL
47
Vitamin A toxicity: clinical manifestations, treatment
- **Seizures**: BZD - Hepatotoxicity: N-acetylcysteine - Idiopathic intracranial HTN (IIH): Acetazolamide, furosemide, high-dose steroids
48
Vitamin D toxicity: clinical manifestations, treatment
**Hypercalcemia** - IV fluids, calcitonin+Bisphosphonate - Severe: hydrocortisone or prednisone
49
Vitamin E toxicity: clinical manifestations, treatment
- **Coagulopathy** - Symptomatic and supportive care
50
Vitamin B6 toxicity: clinical manifestations, treatment
- Incoordination, ataxia, seizures - BZD
51
Niacin toxicity: clinical manifestations, treatment
- NVD, hepatotoxicity, **HoTN** - Symptomatic and supportive care
52
Iron toxicity antidote Deferoxamine indication
Continued vomiting, toxic appearance, lethargy, HoTN + shock/metabolic acidosis, [iron] >500 mcg/dL
53
Iron toxicity antidote Deferoxamine: endpoint of therapy
X continue >24 hrs - Clinically well appearing + normal vital signs Resolution of anion gap metabolic acidosis - No further change in urine color - Serum [iron] ~100 mcg/dL
54
Caffeine toxicity: clinical manifestations
- GI N, intractable **vomiting** - Cardiopulmonary: tachy, **HoTN**, hyperventilation, resp failure - Neurological: HA, agitation, hallucinations, **seizures** - Musculoskeletal: tremor, fasciculation, hypertonicity, rhabdomyolysis
55
Caffeine toxicity treatment
1. ABCs 2. GI decontamination = **Gastric lavage** (>50 mg/kg ingested + w/i 1 hr) 3. Symptomatic & Supportive care: - Intractable vomiting: ondansetron, metoclopramide - HoTN: IV fluids, vasopressors (phenylephrine), **BB** - SVT: BZD + esmolol - Seizures: BZD > propofol or barbiturates - Electrolyte repletion 4. Hemodialysis if indicated
56
Caffeine toxicity treatment: HoTN - beta-blocker agents
Esmolol, propranolol, metoprolol tartrate
57
Caffeine toxicity tx: Hemodialysis indication
**[Caffeine] >100 mg/L**, seizures, life-threatening dysrhythmias, shock
58
Clenbuterol toxicity: clinical manifestations
In overdose, lose beta-2 specificity - GI: gastritis, V - CV: tachy, palpitations, chest pain, atrial fibrillation, myocardial infarction - Electrolyte imbalance: **hypokalemia**, hypoMg, hypophosphatemia
59
Clenbuterol toxicity management
1. ABCs 2. GI decontamination: **AC** 3. Symptomatic & supportive - IV fluids - Tachy: BB (Esmolol, propranolol, metoprolol) - Electrolyte repletion
60
Type I hypersensitivity
- Immediate - IgE - Requires sensitization - Anaphylaxis, acute asthma, urticaria
61
Type II hypersensitivity
- Autoimmune - IgG or IgM - Hemolytic anemia, thrombocytopenia, agranulocytosis
62
Type III hypersensitivity
- Immune complex - IgG or IgM - Tissue damage, serum sickness
63
Type IV hypersensitivity
- Delayed-type - T-cell mediated - Typically dermatologic
64
Clinical criteria for anaphylaxis
1. Acute onset with skin-mucosal involvement &: - Resp compromise or - Decreased BP, syncope or collapse 2. 2+ after exposure to likely allergen: - Skin-mucosal involvement - Resp compromise - Decreased BP, syncope, or collapse - GI 3. Decreased BP after exposure to known allergen
65
Anaphylaxis s/s
Angioedema, flushing, pruritus w/o rash, dyspnea, wheezing, HoTN, NVD
66
Anaphylaxis EPI administration
IM; IV not recommended
67
Anaphylaxis tx adjunctive therapy
- Antihistamines: diphenhydramine (H1), Famotidine (h2) - Glucocorticoids: methylprednisolone
68
ASA & NSAIDs hypersensitivity
- **Rhinitis, asthma, urticaria, angioedema**, sinusitis, anaphylaxis, pneumonitis, aseptic meningitis
69
Mast cell-mediated angioedema: presentation, treatment
- Urticaria, pruritus - **EPI 0.3-0.5 mg IM**, antihistamines, glucocorticoids
70
Bradykinin-mediated angioedema: presentation, treatment
- GI mucosa w/ bowel edema; **NOT** urticaria, pruritus - **Supportive care, C1 inhibitors (Berinert, Ruconest) or kallikrein inhibitors (Ecallantide)**
71
Hereditary Angioedema (HAE): characteristic, prophylaxis, treatment
**Recurrent attacks** - Cutaneous angioedema w/o. AE and severe abdominal symptoms, genital bladder, muscle, joint swelling - Mostly do not require routine prophylaxis: cinryze IV, haegarda, lanadelumab - Berinert, Ruconest, Ecallantide, Icatibant
72
TCA toxicity diagnosis
- Lethargy, coma, seizures, CV collapse - **QRS >100 msec**, prolonged QTc
73
TCA toxicity management
1. ABC, IV access, stabilize vital sign, supportive care 2. Contact poison control 3. GI decontamination: gastric lavage, AC (w/i 2 hrs)
74
1st line treatment for TCA-induced cardiac conduction defects, arrhythmias, HoTn
Sodium Bicarbonate
75
TCA-induced ventricular arrhythmias tx
Lidocaine, hypertonic saline
76
TCA-induced torsades de pointe tx
Magnesium
77
TCA-induced HoTN tx
Crystalloids, NE
78
TCA-induced seizures tx
BZD, propofol, barbiturate (avoid phenytoin)
79
TCA-induced refractory symptoms tx
Lipid emulsion therapy (Intralipid)
80
SSRI toxicity presentation
- QT prolongation: citalopram >600, escitalopram >300 - Seizures: dose related
81
SNRI toxicity presentation
- Tachy, HTN, tremor, mydriasis, mild-mod sedation - CV rare - Seizure: early after ingestion (venlafaxine)
82
Trazodone toxicity symptoms, tx
- CNS depression, ataxia, dizziness - Supportive care; improve w/i 6-12 hrs, resolve by 24 hrs
83
Mirtazapine toxicity symptoms, tx
- CNS depr, sedation, sinus tachy, mild HTN - Supportive care
84
Bupropion toxicity symptoms, tx
- Tachy, HTN, tremor, drowsiness, GI, agitation, seizures, QRS/QTc prolongation - Supportive care: AC, WBI, BZD, sodium bicarb, Mg sulfate, IV, emulsion therapy
85
Serotonin Syndrome (SS) clinical presentation
- Cognitive: insomnia, restlessness, anxiety, altered level of consciousness, agitation - Autonomic: Tachy, HTN, mydriasis, **hyperthermia**, diaphoresis - Neuromuscular: akathisia, incoordination, hyperreflexia, myoclonus, tremor
86
SS treatment
1. D/c offending agent 2. Supportive care 3. BZD if sedation 4. Serotonin antagonist (antidote) = **Cyproheptadine**
87
Neuroleptic Malignant Syndrome (NMS) presentation
- **Fever**: x relieved w/ antipyretics - **Muscular rigidity**: Parkinsonian or "lead pipe" - **AMS**: confusion, stupor, coma, agitation - **Autonomic dysfunction**: tachycardia/pnea, BP lability
88
NMS diagnosis
- Increased creatinine kinase >1000 IU/L - Increased ALT/AST - Leukocytosis - Rhabdomyolysis, myoglobinuria
89
NMS treatment
1. D/c NMS-potentiating meds 2. Supportive care: ventilation, oxygen, IV fluid rehydration, temp reduction, **BZD** 3. Pharmacologic : **Dantrolene, DA agonist (bromocriptine, amantadine)**
90
Carbon Monoxide (CO) toxicity management
1. ABCs 2. **Oxygen therapy**: supplemental oxygen delivery, hyperbaric oxygen 3. IV fluids +/- vasopressors for HoTN 4. Monitor & manage dysrhythmias/myocardial ischemia
91
Cyanide (CN) gas characteristic
Bitter almond smell
92
CN toxicity diagnostic testing
**Significant lactic acidosis (>8)**, elevated venous oxygen saturation
93
CN toxicity management
1. ABCs 2. Rapid identification: arterial blood gas, serum lactate 3. Prompt antidotal therapy: **hydroxocobalamin IV, sodium nitrite, -> sodium thiosulfate**
94
Methemoglobinemia toxicity
- Iron Fe2+ loses 1 electron into Ferric Fe3+ = MetHb >1% - Anemia, CHF, resp disease
95
MetHb diagnostic testing
**Arterial blood gas** - Brown color if significant
96
MetHb management
1. ABC 2. Supportive care, ABG, decontamination 3. High flow O2 4. MetHb level - <30%: asymptomatic -> observe; symptomatic -> methylene blue - >30% -> methylene blue
97
Mushrooms: Cyclopeptide - Amatoxin, Phallotoxin
- Amanita spp - Fatal due to hepatic toxicity
98
Mushrooms: Gyromitrin
- Gyromitra spp - False morel - Neurological symptoms
99
Mushroom poisoning: acute onset <6 hrs: tx for dehydration, vomiting, agitation
- Dehydration, electrolyte abnormalities, hypoglycemia -> IV fluids, electrolytes, glucose - Vomiting -> IV ondansetron - Agitation -> IV BZD
100
Mushroom poisoning: delayed onset >6 hrs: tx for shock, renal insufficiency, agitation, liver/renal failure
- Shock -> IV fluids, vasopressors - Renal insufficiency -> dialysis - Agitation, seizures -> IV BZD - Liver/Renal failures -> organ transplant
101
Mushroom poisoning: hospitalization
1. Delayed symptoms >6 hrs 2. Early symptoms <3 hrs who remain symptomatic >6 hrs despite supportive care 3. Rhabdomyolysis, liver toxicity, renal insufficiency 4. Asymptomatic with amatoxin-containing mushrooms strongly suspected 5. Asymptomatic whom follow-up at 24 hrs cannot be assured
102
Mushroom poisoning: CNS antidote for gyromitrin
**Pyridoxine** + IV **BZD** if seizures present
103
Cyanide poisoning causes
1. Fruit pits and seeds: cherry, apricot, peach, plum, pear, almond, apple (amygdalin) 2. Yuca
104
Toxic plant and berry ingestion antidote
- Anticholinergic: physostigmine - Cardiac glycoside: DigFab

Poison/Toxicology (3 decks)

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