Introduction PT. 2

Question 1

An abnormal, undesirable harmful, or effect to the well-being that is indicated by some measurable endpoint.

Answer 1

ADVERSE EFFECT

Question 2

Chromosomal breakage resulting in rearrangement of pieces of chromosomes.

Loss, addition or rearrangement of chromosomes.

Answer 2

CLASTOGENESIS

Question 3

Chemical with molecular weights of less than 1000 and generally react with endogenous carrier molecules to become antigens before they exhibit immunogenicity.

Answer 3

HAPTENS

A well-known example of a hapten is urushiol, which is the toxin found in poison ivy.

Question 4

Heritable changes in genetic material that are limited to the effects on the nucleic acid.

Vinca alkaloids; Bromine containing cmpds.

Answer 4

MUTAGENESIS

Question 5

Toxicity associated with any chemical substance.

Answer 5

INTOXICATION

on purpose

Question 6

A clinical toxicity secondary to accidental exposure.

Answer 6

POISONING

Not on purpose

Question 7

An intentional exposure with intent of causing self-injury or death.

Answer 7

OVERDOSE

Question 8

Are drugs that have almost exclusively harmful effects

Answer 8

POISON

Question 9

This means that a chemical will produce injury to one kind of living matter without harming another form of life, even though the two may exist close together.

Answer 9

SELECTIVE TOXICITY

Question 10

Study of malformations induced during development conception to birth

Answer 10

TERATOLOGY

Question 11

Synonymous with harmful in regard to the effects of chemicals

Or it relates to poisonous or harmful effects on the body

Answer 11

TOXIC

Question 12

Refers to toxic substances produce naturally

Answer 12

TOXIN

Question 13

Log dose that can produce 50% mortality in a population

Dose that is required to kill half the members of a tested population after a specified test duration

Answer 13

LD50 OR MEDIAN LETHAL DOSE

Question 14

The ability of a chemical agent to cause injury in a given situation or setting

Answer 14

HAZARD

Question 15

It is defined as the expected frequency of the occurrence of an undesirable effect arising from exposure to a chemical or physical agent.

Answer 15

RISK

Question 16

Amount of exposure to a given agent that is deemed safe for a period of time.

Answer 16

THRESHOLD LIMIT VALUE (TLV)

Question 17

Suggests that there should be a dose or exposure level below which harmful or adverse effects are not seen in a population

Answer 17

THRESHOLD DOSE

Question 18

Quantity of agent that can kill an organism

Answer 18

LETHAL/FATAL DOSE

Question 19

Denotes the altered pharmacodynamics of a drug when given in toxic dosage, since normal receptors and effector’s mechanisms may be altered.

Answer 19

TOXICODYNAMICS

Question 20

Applied to the pharmacokinetics of toxic doses of chemicals, since the toxic effects of an agent may alter normal mechanisms for absorption, metabolism or excretion of a foreign material

Answer 20

TOXICOKINETICS

Question 21

Is defined as the apparent
volume into which a substance is distributed.

Answer 21

VOLUME OF DISTRIBUTION (VD)

Question 22

REMEMBER

A drug with a high Vd has a propensity to leave the plasma and enter the extravascular compartments of the body, meaning that a higher dose of a drug is required to achieve a given plasma concentration. (High Vd-> More distribution to other tissue).

Answer 22

Conversely, a drug with a low Vd has a propensity to remain in the plasma meaning a lower dose of a drug is required to achieve a given plasma concentration. (Low Vd-> Less distribution to other tissue).

Question 23

LARGE VD >5L/kg

• Antidepressants
• Antimalarials
• Narcotics
• Propranolol
• Antipsychotics
• Verapamil

Answer 23

LARGE VD >5L/kg

Question 24

SMALL VD <5L/kg

• Salicylates
• Phenobarbital
• Lithium
• Valproic Acid
• Warfarin
• Phenytoin

Answer 24

SMALL VD <5L/kg

Question 25

A measure of the volume of plasma that is cleared of drug per unit time.

Answer 25

CLEARANCE * Zero order (have a rate constant and half-life that is independent of the reactants' concentrations) * First order (have rate constants that are affected by the concentration of the reactants) ## Footnote **Total clearance** is the sum of clearances by excretion by the kidneys and metabolism by the liver.

Question 26

# **NOTE**: ABOUT CLEARANCE In planning detoxification strategy, it is important to know the contribution of each organ to total clearance. For example, if a drug is 95% cleared by liver metabolism and only 5% cleared by renal excretion, even a dramatic increase in urinary concentration of the poison will have little effect on overall elimination.

Question 27

# **NOTES:** Initial approach to the poisoned patient should be essentially similar in every case, irrespective of the toxin ingested, just as the initial approach to the trauma patient is the same irrespective of the mechanism of injury.

Question 28

# **Initial approach to the poisoned patient:** This approach, which can be termed as **routine poison management**, essentially includes the following aspects:

Answer 28

* Stabilization: ABC’s * Clinical Evaluation: Px history, Physical examination * Decontamination: Prevention of absorption * Specific antidote * Removal of absorbed toxin: Enhancing excretion * Supportive therapy: Monitoring adverse effects * Detoxification: Preventive education

Question 29

In the initial evaluation of a toxic patient, it is a must to remember that the most common cause of airway obstruction in the unconscious patient is ______.

Answer 29

Passive obstruction by the tongue | AIRWAYS

Question 30

For many patients, simple positioning in the ____ is sufficient to move the flaccid tongue out of the airway. | AIRWAY

Answer 30

Lateral decubitus position

Question 31

Also, it should be cleared of ____ or any other obstruction and an oral airway. The **head tilt chin lift** or **neck lift with jaw thrust** may be the first maneuver on the unconscious poisoned patient followed by ______. | AIRWAY

Answer 31

- vomitus - endotracheal intubation.

Question 32

A soft, flexible tube is passed through the nose and into the trachea using a “blind” technique.

Answer 32

NASOTRACHEAL

Question 33

The tube is passed through the mouth into the trachea under “direct” vision

Answer 33

OROTRACHEAL

Question 34

DISADVANTAGES ● Perforation of the nasal mucosa, with epistaxis (nose bleed) ● Patient must be breathing spontaneously. ● Anatomically more difficult in infants because of anterior epiglottis. ADVANTAGES ● May be performed in a conscious patient without requiring paralysis. ● Once placed, it is better tolerated than orotracheal tube.

Answer 34

NASOTRACHEAL

Question 35

DISADVANTAGES ● frequently requires neuromuscular paralysis, creating risk of fatal respiratory arrest if intubation is unsuccessful ● requires neck manipulation, which may cause spinal cord injury after neck trauma ADVANTAGES ● performed under direct vision, making accidental esophageal intubation unlikely ● insignificant risk of bleeding ● patient need not be breathing spontaneously ● higher success rate than that with nasotracheal route

Answer 35

OROTRACHEAL

Question 36

The major cause of morbidity of poisoned and drugged patient is _______ difficulties

Answer 36

BREATHING

Question 37

# **NOTES** Patients may have one or more of the following complications: * Ventilatory failure, * Hypoxia (low O2 level), or * Bronchospasm | BREATHING

Question 38

Breathing should be assessed by?

Answer 38

- Observation and - Oximetry and, if in doubt, - By measuring arterial blood gases (ABG)

Question 39

Patients with respiratory insufficiency should be ____ and ____

Answer 39

intubated; mechanically ventilated

Question 40

Administer supplemental oxygen as indicated based on arterial PO2. Intubation and assisted ventilation may be required. If carbon monoxide poisoning is suspected, give 100% oxygen. | MANAGEMENT

Answer 40

Correct hypoxia

Question 41

Obtain frequent sputum samples and initiate appropriate antibiotic therapy when there is little evidence of infection. | MANAGEMENT

Answer 41

Treat Pneumonia

Question 42

There is no basis for prophylactic antibiotic treatment of aspiration- or _____. | MANAGEMENT

Answer 42

chemical-induced pneumonia

Question 43

Although some physicians recommend _____ for chemical-induced pneumonia, there is little evidence of their benefit. | MANAGEMENT

Answer 43

corticosteroids

Question 44

It may result from the following: * Direct irritant injury from inhaled gases or pulmonary aspiration of petroleum distillates or stomach contents. * Pharmacologic effects of toxins e.g. organophosphate or carbamate insecticides or beta-adrenergic blockers. * Hypersensitivity or allergic reactions

Answer 44

Bronchospasm

Question 45

Treatment of Bronchospasm

Answer 45

1. Administer supplemental **oxygen**. 2. Remove the patient from the **source of exposure** to any irritant gas or other offending agent. 3. Immediately **discontinue** any beta-blocker treatment. 4. Administer **bronchodilators**: Aerosolized ß2 stimulant (eg, albuterol 2.5 in nebulizer)

Question 46

If this is not effective, and particularly for **beta blocker induced wheezing**, give _____, ___ mg/kg IV over ___ minutes. | This* is referring to Tx of Bronchospasm

Answer 46

aminophylline; 6; 30

Question 47

For patients with **bronchospasm** and **bronchorrhea** caused by **organophosphate** or other **anticholinesterase poisoning**, give _____

Answer 47

atropine

Question 48

The circulation should be assessed by continuous monitoring of the following:

Answer 48

1. pulse rate, 2. blood pressure, 3. urinary output, and 4. evaluation of peripheral perfusion

Question 49

An **intravenous line** should be placed and blood drawn for _________ and other routine determinations.

Answer 49

serum glucose

Question 50

___________ in the toxic patient must be addressed as quickly as possible in order to avoid the sequelae of shock

Answer 50

Hypotension ## Footnote A fluid challenge of 100-200 mL of a crystalloid solution (10-20 mL/kg in pediatrics) is often given at this time while urine output is monitored (0.5-1 mL/kg/hour).

Question 51

If the patient’s mental status is altered or if hypotension exists, **four essentials** are administered.

Answer 51

Thiamine, Oxygen, Naloxone, & Glucose | T-O-N-G

Question 52

This can be especially effective in Px with limited glycogen stores (e.g. neonates and patients w/ cirrhosis) | Drugs to be utilized in toxic Px with altered mental status

Answer 52

25-50g of dextrose IV to reverse the effects of drug-induced hypoglycemia (adult) 1mL/kg and diluted 1:1 (child) ## Footnote Extravasation into the extremity of this hyperosmolar solution can cause VOLKMANN'S contractures

Question 53

Prevent WERNICKE's encephalopathy | Drugs to be utilized in toxic Px with altered mental status

Answer 53

50-100mg of IV thiamine ## Footnote a water soluble vitamin with low toxicity; rare anaphylactoid reactions have been reported

Question 54

Specific opioid antagonist without any agonist properties | Drugs to be utilized in toxic Px with altered mental status

Answer 54

Initial dosage of Naloxone

Question 55

Useful for carbon monoxide, hydrogen, sulfide, and asphyxiants | Drugs to be utilized in toxic Px with altered mental status

Answer 55

Oxygen, utilized in 100% concentration ## Footnote While oxygen is antidotal for carbon monoxide intoxication, the only relative toxic contraindication is in paraquat intoxication (in that it can promote pulmonary fibrosis).

Question 56

______ are due to intentional suicidal overdose by an adolescent or adult.

Answer 56

Acute poisoning

Question 57

Childhood deaths due to ________ of a drug or toxic household product.

Answer 57

accidental ingestion

Question 58

# **REMEMBER** Careful management of: * Respiratory failure * Hypotension * Seizure * Thermoregulatory disturbances ... will result in an improved survival of patients who reach the hospital alive