Final: Toxicology Flashcards by TheOneandOnly Ash

What are the 3 most common drug-related overdoses in adults?

Analgesics
Antidepressants
Cardiovascular drugs

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What are the 2 most common drug-related overdoses in kids?

Analgesics

Dietary supplements/herbals/homeopathic

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What are the 3 steps to caring for a patient with suspected overdose?

Stabilization
Exposure
Assessment

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What is involved in Step 1: Stabilizing?

*ABC Management
-Airway
-Breathing
Circulation

Oxygenation

Vital Signs

IV Access

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What is involved in Step 2: Exposure?

Determine:
-Medications/illicit substances taken
-Doses
-Time of ingestion
-Family/EMS reports
-Pill count

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What is involved in Step 3: Assessment?

-Physical exam
-Labs
-APAP/Salicylate concentrations
-EtOH/Toxic alcohol panel
-Decontamination needed?
-Antidote needed?

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What are the symptoms of an anticholinergic toxicity?

Blind
Hot
Red
Mad/crazy
Dry

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What are common decontamination strategies?

Activated Charcoal
Whole Bowel Irrigation
Hemodialysis

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What is the dosing of activated charcoal used for decontamination?

1-2 g/kg ABW
or
50-100 g in adults

*one tube is about 50g, typically what is used

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Hemodialysis is effective for which medications?

Alcohols
Lithium
Salicylates
Theophylline

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*What dose of salicylates is indicative of Mild Toxicity and what are some common side effects?

> 30 mg/dL

-tinnitus
-dizziness

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*What dose of salicylates is indicative of Severe Toxicity and what are some common side effects?

> 80 mg/dL

-CNS effects

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How soon after ingestion must activated charcoal be administered for it to work?

1-2 hrs

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Regarding general management of overdose, what are some things that we specifically do to manage salicylate overdoses?

Stabilization
Exposure

Assessment
-Salicylate/APAP concentrations
-Activated charcoal if within 2 hrs
-Fluids with KCl to counteract electrolytes
-Sodium bicarb
-Hemodialysis -possible

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*What is our main antidote for salicylate toxicity?

Sodium Bicarbonate

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What things do we do as part of the assessment phase that are specific for sedative overdose?

EtOH/ toxic alcohol panel
Activated charcoal?
Flumenazil?

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What is the main antidote available for sedative toxicity?

Flumazenil

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What is the moa of flumazenil?

Competes with benzodiazepines at the BZD binding site of the GABA complex

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**Why is Flumazenil use limited?

Must be used with caution in pts with history of seizures

-Can induce seizure activity
-Blocks the action of benzodiazepines which are the main drug class used for seizures. If we knock out these drugs then how are we supposed to treat someone’s seizure

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What are examples of tricyclic antidepressants?

Amitriptyline
Desipramine
Doxepin
Imipramine
Nortriptyline

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What properties of tricyclic antidepressants make them “dirty drugs” and contribute to their toxicity?

Rapidly absorbed from GI tract
-anticholinergic effects slow GI motility
-decreased rate of absorption

Large Vd

Acidemia increases the % of unbound drug

Highly lipophilic

Long half life

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What are the symptoms of TCA toxicity?

Altered mental status
Hypotension
Tachycardia
Prolonged QRS
Seizures

Anticholinergic symptoms:
Blind, Hot, Red, Mad, Dry

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What is the cutoff for a normal QRS interval?

Study These Flashcards

<100

What QRS interval has an increased risk of seizure activity?

Study These Flashcards

> 100

What QRS interval has an increased risk of cardiac arrhythmias?

>150

What promotes unbinding of drug from proteins?

Metabolic acidosis

What things do we do as part of the assessment phase that are specific for TCA overdose?

Activated charcoal? Fluids Vasopressors Seizure management Sodium bicarbonate

What is the antidote for TCA toxicity?

Sodium Bicarbonate

When can we discontinue sodium bicarbonate for TCA toxicity?

QRS interval < 100 Resolution of ECG abnormalities Hemodynamically stable

What 2nd line seizure management therapies may not work as well after giving sodium bicarbonate for TCA toxicity?

Phenytoin Fosphenytoin Levetiracetam

What is the function of First Generation antipsychotics?

D2 antagonism

What is the function of Second Generation antipsychotics?

5HT2A/D2 antagonism

What are examples of antipsychotics?

Typical: -Haloperidol -Fluphenazine -Chlorpromazine -Thioridazine -Perphanazine Atypical: -Aripiprazole -Clozapine -Olanzapine -Paliperidone -Ziprasidone

What are the symptoms of antipsychotic toxicity?

Hypotension Tachycardia QT/QRS prolongation Extrapyramidal symptoms Neuroleptic malignant syndrome Sedation

What therapies can be given to treat extrapyramidal symptoms with antipsychotics?

Benztropine *IM Diphenhydramine *IV/IM, then oral for 3-4 days

What are the symptoms of neuroleptic malignant syndrome?

Hyperpyrexemia up to 42.2C (108F) Altered mental status (delirium or coma) "Lead pipe" muscular rigidity Continues for 5-10 days

What are the most common agents that cause Neuroleptic Malignant Syndrome?

Haloperidol Depot Fluphenazine Chlorpromazine

What is the treatment for Neuroleptic Malignant Syndrome?

*d/c offending agent External cooling Benzodiazepines (relax muscles) **Dantrolene -antidote, 1st line Bromocriptine -2nd line, oral option

What are the 3 symptoms of serotonin syndrome?

Altered mental status Autonomic instability Neuromuscular abnormalities

What is the treatment for serotonin syndrome?

d/c offending agent Benzodiazepines Aggressive Cooling Cyproheptadine** -1st gen histamine receptor blocking agent

**How can you tell the difference between Serotonin Syndrome and Neuroleptic Malignant Syndrome?

SS: -Lower fever -Lasts < 24 hrs -Responds to cyproheptadine -Lower limbs are more affected than upper limbs NMS: -Higher fever -Lasts > 24 hrs -Responds to bromocriptine -Diffuse lead pipe rigidity

What makes digoxin particularly prone to toxicity?

Narrow therapeutic index

What is the major side effect that acts as a key indicator of Digoxin toxicity?

Hyperkalemia (5-6.4)

How do we manage digoxin toxicity?

d/c drug ABC management *Obtain serum digoxin concentrations, BMP Monitor vitals and ECG changes Administer activated charcoal (if within 2 hrs) *Consider administering Digibind *Hemodialysis is NOT effective

When is Digibind indicated in Digoxin toxicity?

Arrythmias, Bradycardia Hyperkalemia >5.5 with s/s of toxicity Serum digoxin concentrations > 10-15 ng/mL -drawn at least 6 hours after time of ingestion Ingestion > 10mg in adults, > 4mg in children

Each vial of Digibind binds how much Digoxin?

0.5mg

How do we calculate how many Digibind vials a patient needs?

Based on known amount: Total Body Load (TBL)= mg digoxin ingested x 0.8 TBL/0.5= # vials to administer Based on serum concentration: vials= (digoxin concentration x patient's weight [kg])/ 100

How do we manage CCB and BB toxicity?

ABC management Monitor vital signs and ECG changes Administer activated charcoal -depending on dosage form and time

What are the potential antidotes for BB and CCB toxicity?

Atropine Calcium Vasopressor Therapy Glucagon High dose insulin therapy Lipid emulsion therapy

What are some considerations with using Atropine as an antidote in BB and CCB toxicity?

Blocks parasympathetic activity to increase heart rate Readily available, but usually not effective Will see in seconds if it is going to work

What are some considerations with using Calcium as an antidote in BB and CCB toxicity?

-Opens calcium channels and promotes release of calcium from the sarcoplasmic reticulum which results in myocardial contractility -Calcium chloride has 3x more elemental calcium than calcium gluconate *More effective in CCB overdose than BB overdose

What are some considerations with using vasopressor therapy as an antidote in BB and CCB toxicity?

Binds beta receptors not occupied by BB and Gs receptors to eventually stimulate cAMP and calcium release to improve contractility May require high doses to overcome receptor blockade The agent chosen depends on clinical presentation: -Vasodilatory shock= Norepinephrine -Cardiogenic shock= Epinephrine

What are some considerations with using glucagon as an antidote in BB and CCB toxicity?

-Stimulates contractility by bypassing beta receptors and binding to Gs receptors to activate conversion of ATP to cAMP *May need to pre-medicate with ondansetron and add a prn regimen due to N/V with glucagon

What are some considerations with using lipid emulsion therapy as an antidote in BB and CCB toxicity?

Limits bioavailability of lipophilic medication by creating a "lipid sink" Max dose: 10mL/kg

What toxicity is activated charcoal not useful for?

Iron toxicity

How do we treat iron toxicity?

Polyethylene glycol (whole bowel irrigation) Antidote: Deferoxamine

Final: Toxicology Flashcards

(56 cards)