- Focus on toxic effects in patients by unintentional or intentional overdoses ~77% are unintentional

Lecture 35: Toxicology Flashcards by Emily Byford

What is Toxicology?

Focus on toxic effects in patients by unintentional or intentional overdoses

~77% are unintentional

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What are some of the Top Medications Overdose in Adults?

Analgescis [11.2%]
Sedatives/Hypnoyics/Anti-Psychotics [9.8%]
Antidepressants [7.2%]
Cardio Drugs [6.4%]
Alcohols [4.8%]

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What are some of the Top Medications Overdoses in Children?

Analgesics [9.2%]
Antihistamines [4.7%]
Vitamins [4.3%]

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What are some of the first things to consider when helping a potentail overdose patient?

Stabilization? Exposure? Assessment?

Stabilization: ABC management, Vitals, IV access, Oxygenation
Exposure: What drugs, How much, When taken
Assessment: Exams/Labs, APAP/Salicylate Tests, Andtidotes?

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What is the Anion Gap & Osmolar Gap?

Calculations?

Anion Gap: difference of Cations and Anions [(Na+K)-(Cl+HCO3)] should be < 14
Osmolar Gap: Gap = Measured - Calculated [Calculated = (2xNa)+(BUN/2.8)+(Glu/18)+(EtOH/4.6)] should be < 10

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What is the importacne of Activated Charcoal?

Best used in 2-4 hours [44-95% prevention]
Hard to take; bad taste and gritty
1-2g/kg ABW

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What are some of the Signs and Symptoms of Opioid Toxicity?

Respiratory Depression
Pinpoint Pupils
N/V
Drowsiness
Bradycardia
Hypotension

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What is the General Managment of Opioid Toxicity?

Stabilization? Exposure? Assessment?

Stabilization: ABC Management [NEED TO DO], CNS/Respiratory Management
Exposure: What Drug, How much, When?
Assessment: Labs/Exams, APAP/Salicylate Test, Naloxone

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What is the Treatment of Choice for Opioid Toxicity?

NALOXONE 0.4 - 2mg IV push, IM, IN
Want to give the smallest amount to AVOID withdrawal
HIGHER doses for those with illicit drugs use

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What are some of the Risk Factors for Acetaminophen Toxicity?

Dose? Conditions?

Toxic Dose = 7.5-15g
Risk Conditions: Those taking 2E1 Inducers & Alcohol

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What is the Pharmacology of Acetaminophen?

60%: Glucaronidation
30%: Sulfation [more protective in kids]
~10%: 2E1 = necrosis

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What is the overall Timeline for Acetaminophen Toxicity?

0-24h: no real symtpoms
24-48h: Liver issues begin
48-72h: More liver issues & increased bilirubin
72-96h: Highest liver issues then Hepatic Encephalopathy, Renal Failure, Death

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What is the Treatment Options for Aceteminophen Toxicity?

MOA? When to start? Duration?

N-Acetylcysteine [NAC]
MOA: Glutathione Surrogate that pushes more toward Glucoronidation pathway
Best to start withinn 8 hours
IV = 21h & PO = 72h
Rumack-Matthew [above line = GIVE NAC & below line = HOLD NAC]

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What is the Dosing Regimen for N-Acetylcystine?

IV? PO?

IV: Loading Dose [150mg/kg IV over 1h] –> Second Dose [50mg/kg IV over 4h] –> Third Dose [100mg/kg IV over 16h]
PO: Loading Dose [140mg/kg] –> Maintenance Dose [70mg/kg PO q4h for 17 doses]

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What are some of the Risk Factors for Salicylate Toxicity?

Disorders? Concentraions?

Disorders: Mixed Acid/Base = Increased Anion Gap [metabolic acidosis] & Hyperventilation [Respiratory Alkalosis]
Concentrations: Mild Toxicity = >30 [tinnitus, diszziness] & Severe Toxicity = > 80 [CNS effects]

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What are some of the Signs and Symptoms of Salicylate Toxicity?

Tinnitus & Vertigo
Seizure
N/V
Lethargy/Coma
Decreased GI Motility
Altered Mental Status

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What is the General Managment of Sakicylate Toxicity?

Stabilization? Exposure? Assessment?

Stabilization: ABC, IV, Vitals, Oxygen
Exposure: When, How Much, What Drug
Assessment: Exams/Labs, Sodium Bicarb

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What is the Treatment of Choice for Salicylates Toxicity?

MOA? Monitoring?

Sodium Bicarb 1-2mEq/kg IV push over 1-2mins
MOA: Urine Alkalinization
For Salicylate Conc. > 30, Anion Gap Acidosis, Altered Mental
Monitor pH & Electrolytes

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What are some of the Signs and Symptoms of Sedative Toxicity?

CNS Depression
Respiratory Depression
Bradycardia
Hypotension

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What is the General Managment of Sedative Toxicity?

Stabilization: ABC, IV, Vitals, Oxygen
Exposure: When, How Much, What Drug
Assessment: Exams/Labs, Flumazenil?

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What is the Treatment of Choice for Sedative Toxicity?

MOA? Side Effects? Is it really used?

Flumazenil 0.2mg IV push
MOA: competing with BZDs at the GABA site [complete inhibitor]
Can cause withdrawal symtpoms [causes seizures]
NOT RECOMMENDED because of its FULL INHIBITION of GABA

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What are some of the Indications and ** Examples** of TCAs?

Study These Flashcards

Indications: Bed wetting, Depression, Insomnia, Mirgraines, Neruopathy
Examples: Amitriptyline, Nortiptyline, Doxepin…

What are some of the signs and symptoms for TCA Toxicity?

Study These Flashcards

Prolonged QRS
Anticholinergic Symptoms
Seizures
Altered Mental Status
Hypotension
Tachycardia

Antichoinergic: Blind as a Bat, Hot as Hades, Red as a Beat, Dry as a Desert, Mad as a Hatter

What are some of the effects of the QRS Prolongations within TCA use?

Study These Flashcards

> 100 msec = increase seizure risk
> 150 msec = increased cardiac arrhythmias

What is the **treatment** for **TCA Toxicity**? ## Footnote MOA? Indications? Monitoring?

- **Sodium Bicarb** 1-2 mEq/kg IV push over 1-2 mins - MOA: Increase sodium gradient - Indications: QRS > 100, Arrhythmias, Acidosis - Monitoring: pH 7.45-7.55; QRS < 100, Stable

What are some of the **Examples** of some of the Antipsychotics? ## Footnote Pharmacology?

- Typical: Haloperidol, Fluphenazine, Chlorpromazine, Thioridazine, Perphanazine - Atypical: Aripiprazole, Clozapine, Olanzapine, Paliperidone, Ziprasidone ## Footnote 1st gen: D2 antagonism 2nd gn: Serotonin/D2 antagonis

What are some of the **Signs and Symptoms** of **Antipsychotic Toxicity**?

- Hypotension - Tachycardia - QT/QRS Prolongation - EPS - NMS - Sedation

What is important to know about **Atypical Antipsychotics Toxicity**?

- NOT defined - Symptoms within 1-2h - Peak symptoms within 4-6h - Duration is 12-48h

What are some of the important things to note about **NMS Complications**? ## Footnote Treatment?

- High Fever [108] with very stiff muscles; happens in 3-9d --> Death can happen - Mainly caused by **Haloperidol, Depot Fluphenazine or Chlorpromazine** - DC agent; cooling; Benzos;

What is the **differences** between **Serotonin Syndrome and NMS**?

- Serotonin Syndrome: Lower Fever; Lasts < 24h; Lower Limbs; Cyproheptadine - NMS: Higher Fever; Lasts > 24h; Stiff Muscles; Bromocriptine

What is the cause for **Digoxin Toxicity**?

- Dig blocks Na/K ATPase causing more K to be outside = toxicity

What are some of the **Signs and Symptoms** of **Digoxin Toxicity**? ## Footnote Non-Cardiac? Cardiac?

- Cardiac: Bradycardia, Heart Blocks, Arrhythmias, Hyperkalemia - Non-cardiac: N/V, Ab Pain, Norexia, Confusion, Vision Changes

What is the **General Management** for **Digoxin Toxicity**?

- DC Digoxin - ABC, Vitals, ECG - Activated Charcaol: within 2 hours - **Digibind** - **Hemodialysis NOT Effective**

What is the **Treatment** that is used for **Digoxin Toxicity**? ## Footnote MOA? Indications?

- **Digibind** - MOA: Binds to free dig in the body - Indications: NOT Responsive to Atropine, Hyperkalemia, Ingested > 10mg in adults & > 4mg in kids

What is important to know about the **Dosing** for **Digibind** in **Digoxin Toxicity**?

- Based on the 0.5mg vials - Acute Ingestion: (mg of dig x 0.8) / 0.5mg - Serum Dig: (Dig Conc. x Weight [kg]) / 100 ## Footnote Tells how many Digibind vials we have to give

What are some of the **Signs and Symptoms** for **CCB and BB Toxicity**? ## Footnote What do they have in common?

- CCBs: HYPERglycemia, Metabolic Acidosis, Ileus... - BBs: HYPOglycemia, Bronchospams - BOTH: Hypotension, Bradycardia, Arrhythmias, Cardiogenic Shock, CNS Depression

What is the **General Management** for **CCB and BB Toxicity**? ## Footnote Potential Antidotes?

- ABC, Vitals, ECG - Activated Charcoal [depends on time and amount] - Potential Antidotes: Atropine, Calcium, Vasopressors, Glucagon, High Dose Insulin, Lipid Emulsion

What is the **MOA** for **Atropine** in **CCB and BB Toxicity**? ## Footnote Effective?

- MOA: Blocks Parasympathetic activity to **increase the heart rate** - 0.5-1mg IV push - **NOT ALWAYS EFFECTIVE**

What is the **MOA** of **Calcium** in **CCB and BB Toxicity**? ## Footnote Effective? Dosing?

- MOA: Promotes Ca release = contractility - Dosing: Ca **Cloride** is 3x more better than Ca Gluconate - **MORE** effective in CCB than BB overdose

What is important about **Vasopressor Therpay** in **CCB and BB Toxicity**?

- Higher doses are used - Vasodilatory Shock = Norepinephrine - Cardiogenic Shock = Epinephrine

What is the **MOA** of **Glucagon** in **CCB and BB Toxicity**? ## Footnote Dosing?

- MOA: Causes contractility by hitting Gs to activate ATP to cAMP - Dosing: HIGHER than in diabetes [3-10mg IV in adults] - **Pre-medicate with Ondasetron** to decrease N/V

What is the **MOA** for **High Dose Insulin** in **CCB and BB Toxicity**? ## Footnote Monitoring? Dosing?

- MOA: Increases inotropy - Dosing: titrate to systolic BP > 90-100 - Monitoring: Improved Contractility within 15-60mins, Glu = 100-250, Check Electrolytes

When can **Iron Toxicity** occur within someone?

- 10 - 60 mg/kg of elemental iron

What are the **phases** of **Iron Toxicity**?

- 0.5 - 2h: GI upset, ab pain - 6 - 24h: Recovery? should monitor - 2 - 24h: shock stage [acidosis, hypotension, poor CO] - 48 - 96h: Hepatoxicity - Days - Weeks: GI Scarring, Obstructions...

What is the **General Managment** of **Iron Toxicity**?

- ABC, Vital, Fluids - **Activated Charcoal NOT good** - Whole Bowel Irrigation - Deferoxamine?

What is the **Treatment** for **Whole Bowel Irrigation** in **Iron Toxicity**?

- **Polyethylene Glycol** - Takes 4 - 6h to work; should be by a toilet

What is the **Antidote Treatment** for **Iron Toxicity**? ## Footnote MOA? Indications?

- **Deferoxamine** - MOA: Chelates iron and enhances renal elimination - Indicated: Metabolic Acidosis, Iron Tabs in KUB, Conc. > 500 ## Footnote 15mg/kg/hour

What are some of the **Toxic Alcohols** that are can cause **Toxicity**?

- Ethylene glycol [antifreeze], Methanol [washer fluid, paint remover], Isopropyl Alcohol [rubbing alcohol, paint remover]

What are some of the **Clinical Presentations** assoicated with **Toxic Alcohols** and what are the **results**?

- Anion Gap & Osmolar gap - **Anion gap + Osmolar gap** = Methanol; Ethylene - **Osmolar Gap NO Anion Gap** = Isopropyl

What are the **Phases of Toxicity** for **Alcohol Toxicity**?

- 30 min - 12 h: CNS, N/V, Inebriation, Lethargy - 12 - 24h: Metabolic Effects, Cardio issues, Anion Gap - 2 - 3d: Renal issues, Crystals

What is the **General Managment** of **Ethylene Gylcol and Methanol Toxicity**? ## Footnote Treatment?

- Non-Pharm: Gastric Lavage or Aspirations when < 1h; **Charcoal NOT good** - Pharm: **Ethanol & Fomepizole** --> inhibits alcohol dehydrogenase limiting toxic Metabolites

What is **Fomepizole**?

- Helps with Ethylene and Methanol toxicity - NO CNS depression & ICU not required

What is the **Treatment** of **Isopropyl Toxicity**?

- Hydration - Hemodialysis

Lecture 35: Toxicology Flashcards

(53 cards)