Overdose and poisoning Flashcards by David Houghton

What is the prevalence A&E presentations due to poisoning?

1 - 1-2%
2 - 5-10%
3 - 25-40%
4 - >50%

2 - 5-10%

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5-10% of all A&E admissions are due to poisoning. What number of these are admitted to hospital?

1 - 100,000
2 - 10,000
3 - 1000
4 - 100

1 - 100,000

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Which age group is poisoning most common in?

1 - <5y/o
2 - <18y/o
3 - 30-65 y/o
4 - >65 y/o

1 - <5y/o
- children under 5 typically grab things and eat them

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Which drug class accounts for 50% of all accidental deaths due to poisoning?

1 - Alcohol
2 - Tricyclic antidepressants
3 - Benzodiazepines
4 - Opioids
5 - Paracetamol

4 - Opioids

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Which drug class accounts for 50% of all non-accidental (overdose) deaths due to poisoning?

1 - Alcohol
2 - Tricyclic antidepressants
3 - Benzodiazepines
4 - Opioids
5 - Paracetamol

5 - Paracetamol

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Not all patients who are suspected of drug poisoning are administered to the ICU. Which of the following is NOT a typical drug that causes poisoning and subsequent admission to ICU?

1 - Alcohol
2 - Short acting B2 agonist
3 - Tricyclic antidepressants
4 - Benzodiazepines
5 - Recreational drugs
6 - Opioids
7 - Paracetamol

2 - Short acting B2 agonist

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A-E is the standard approach for any patient with suspected poisoning. However, this is NOT the case in which 2 of the following?

1 - organophosphate poisoning
2 - opioid overdose
3 - smoke inhalation
4 - cyanide if exposed to fire

1 - organophosphate poisoning
4 - cyanide if exposed to fire

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A-E is the standard approach for any patient with suspected poisoning. However, this is NOT the case in organophosphate poisoning or cyanide if exposed to fire. Which of the following is NOT true about organophosphates?

1 - used routinely in farming and industry
2 - cannot be absorbed across the skin but can be inhaled
3 - PPE is required before any assessment on the patient
4 - patients clothes should be removed

2 - cannot be absorbed across the skin but can be inhaled

this is so dangerous because it CAN be absorbed across the skin barrier
crucial that the patient is stripped and you wear PPE

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1 - routinely available
2 - common in house and industrial fires
3 - patient requires an antidote immediately

1 - routinely available
- not common anymore
- BUT can be found in patients that have been in fires

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If you suspect a patient has been poisoned and the substance can be identified, what is the name of the tool that can be used to identify if antidotes or other agents need to be given?

1 - BNF
2 - NICE guidelines
3 - TOXBASE
4 - all of the above

3 - TOXBASE

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A toxidrone is a syndrome of symptoms caused by toxic poisoning. Patients could be poisoned due to excessive anti-cholinergic. Which of the following would NOT happen if a patient took too much of an anti-cholinergic?

1 - increased HR
2 - increased RR
3 - increased BP
4 - increased temperature
5 - increased pupil size
6 - increased bowel movements/sounds
7 - reduced sweating

6 - increased bowel movements/sounds
- we would see reduced bowel movement and sounds
- cholinergics are involved in digestion, so stop these and the bower stops/slows

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A toxidrone is a syndrome of symptoms caused by toxic poisoning. Patients could be poisoned due to excessive anti-cholinergic, which can cause the signs in the picture attached. Which of the following is NOT an anti-cholinergic drug class?

1 - antihistamines
2 - tricyclic antidepressants
3 - antiparkinsonian agents
4 - antispasmodics
5 - phenothiazines (antipsychotics),
6 - nicotine
7 - atropine

6 - nicotine
- this is a cholinergic agonist

Amitriptyline a tricyclic antidepressants is the most common drug used in overdose

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A toxidrone is a syndrome of symptoms caused by toxic poisoning. Patients could be poisoned due to excessive cholinergic. Which of the following would NOT happen if a patient took too much of an cholinergic?

1 - decreased HR
2 - no change in RR
3 - no change in BP
4 - no change in temperature
5 - reduced pupil size
6 - increased bowel movements/sounds
7 - increased sweating

1 - decreased HR
- HR typically doesn’t change

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A toxidrone is a syndrome of symptoms caused by toxic poisoning. Patients could be poisoned due to excessive cholinergic, which can cause the signs in the picture attached. Which of the following is NOT an cholinergic drug class?

1 - antihistamines
2 - organophosphates
3 - carbamate insecticides
4 - nerve agents
5 - nicotine
6 - pilocarpine
7 - edrophonium

1 - antihistamines

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A toxidrone is a syndrome of symptoms caused by toxic poisoning. Patients could be poisoned due to excessive hallucinogenic. Which of the following would NOT happen if a patient took too much of an hallucinogenic?

1 - increased HR
2 - increased RR
3 - increased BP
4 - no change in temperature
5 - increased pupil size
6 - increased bowel movements/sounds
7 - increased sweating

7 - increased sweating
- typically does not affect sweating

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A toxidrone is a syndrome of symptoms caused by toxic poisoning. Patients could be poisoned due to excessive hallucinogens, which can cause the signs in the picture attached. Which of the following is NOT an hallucinogenic drug class?

1 - Phencyclidine
2 - cocaine
3 - LSD
4 - MDMA (ecstasy)

2 - cocaine

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A toxidrone is a syndrome of symptoms caused by toxic poisoning. Patients could be poisoned due to excessive sympathomimetic. Which of the following would NOT happen if a patient took too much of an sympathomimetic?

1 - increased HR
2 - increased RR
3 - increased BP
4 - increased temperature
5 - decreased pupil size
6 - increased bowel movements/sounds
7 - increased sweating

5 - decreased pupil size
- typically they increase ready for fight or flight

A toxidrone is a syndrome of symptoms caused by toxic poisoning. Patients could be poisoned due to excessive sympathomimetic, which can cause the signs in the picture attached. Which of the following is NOT an sympathomimetic drug class?

1 - phencyclidine
2 - cocaine
3 - amphetamines
4 - ephedrine
5 - pseudoephedrine
6 - theophylline
7 - caffeine

1 - phencyclidine

A toxidrone is a syndrome of symptoms caused by toxic poisoning. Patients could be poisoned due to excessive sedative-hypnotic. Which of the following would NOT happen if a patient took too much of an sedative-hypnotic?

1 - reduced HR
2 - reduced RR
3 - reduced BP
4 - reduced temperature
5 - reduced pupil size
6 - reduced bowel movements/sounds
7 - reduced sweating

5 - reduced pupil size
- pupils are typically not affected

A toxidrone is a syndrome of symptoms caused by toxic poisoning. Patients could be poisoned due to excessive intake of a drug causing serotonin syndrome. Which of the following would NOT happen if a patient had serotonin syndrome?

1 - increased HR
2 - increased RR
3 - increased BP
4 - increased temperature
5 - decreased pupil size
6 - increased bowel movements/sounds
7 - increased sweating

5 - decreased pupil size
- typically they increase ready for fight or flight

1 - MAOIs alone or with
2 - MAIOs with SSRIs
3 - tricyclic antidepressants
4 - antihistamines
5 - L-tryptophan

4 - antihistamines

Amitriptyline a tricyclic antidepressants is the most common drug used in overdose

In any patient suspected of poisoning, there is a battery of tests that is typically performed. Which of the following is NOT in this typical list?

1 - ECG
2 - ABG
3 - Bloods – paracetamol and salicylate levels (4 hours post exposure)
Full blood count, urea and electrolytes, lactate, liver function tests, coagulation studies
Levels for specific drugs – methanol, ethylene glycol, carbamazepine, iron, lithium
4 - Urine screen for drugs of abuse
5 - Troponin and CK-MB
6 - CT/X ray – exclude, pulmonary oedema, trauma, head injury, drug smuggling

5 - Troponin and CK-MB

What is the normal pH in humans?

1 - 6.55-7.75
2 - 7.55-8.55
3 - 7.35-7.45
4 - 7.15-7.25

3 - 7.35-7.45

In a patient who is suspected of being poisoned due to excessive drugs, we should always run an ECG as anywhere in the cardiac action potential can be affected. Which 2 classes of medications if taken in excess are most dangerous?

1 - Class I (Na+ channel blockers)
2 - Class II (β-blockers)
3 - Class III (K+ channel blockers)
4 - Class IV (Ca2+ channel blockers)
5 - Others (multiple mechanisms)

2 - Class II (β-blockers)
- sinus bradycardia
- prolonged PR interval

4 - Class IV (Ca2+ channel blockers)
- sinus bradycardia
- atrioventricular blocks
- bundle branch block
- QT prolongation
- junctional arrhythmis

Which of the following is the correct approach for calculating the anion gap? 1 - Cl- add K+ minus (Na+ add HCO3-) 2 - Na+ add K+ minus (Cl- add HCO3-) 3 - K+ add Cl- minus (Na+ add HCO3-) 4 - Mg2+ add Cl- minus (Na+ add HCO3-)

2 - Na+ add K+ minus (Cl- add HCO3-) - normal range is 3-11mEq/L - if value is >16 you should suspect drug use - MUDPILES for anion gap acidosis M = Methanol U = Uremia D = Diabetic ketoacidosis P = Propylene glycol I = Isoniazid or Iron L = Lactic acidosis E = Ethylene glycol S = Salicylates

The mnemonic MUDPILES CAT can be used to identity drugs that increase the anion gap acidosis: M Methanol U Uraemia D DKA P Paracetamol, paraldehyde I Iron, isoniazid L Lactic acidosis E Ethanol, ethylene glycol S Salicylates, ASA, Aspirin C Carbon monoxide Cyanide A Aminoglycosides T Toluene (glue sniffing) Theophylline

- increased anion gap is NOT always caused by drugs - can be physiological changes such as lactic acid or DKA

In addition to the standard A-E approach of someone with poisoning or an overdose when assessing a patient, we need to think about how we can improve pharmacodynamics (what the body does to a drug), which is essentially stop the patient from absorbing more. Which 2 of the following are key approached to achieve this? 1 - skin decontamination 2 - activated charcoal 3 - anti-diarrhoeals 4 - laxatives

1 - skin decontamination - important if the poison is able to perfuse through the skin like organophosphates or nicotine 2 - activated charcoal - important if patient has swallowed - this is a slurry of charcoal that washes out the bowels

Activated charcoal can be given to patients if they have swallowed something that is poisoning them. Which of the following must be present before a patient can be given activated charcoal? 1 - consent 2 - able to swallow (GCS >10) 3 - able to protect their airway and not not aspirate (high GCS >10) 4 - all of the above

4 - all of the above

In addition to the standard A-E approach when assessing a patient, we need to think about how we can eliminate the poisons from the patients body after it has already been absorbed. Which of the following is NOT an approach to do this? 1 - urinary alkainisation 2 - blood transfusion 3 - haemodialysis 4 - haemoperfusion

2 - blood transfusion - urinary alkainisation = patient given lots or HCO3- to raise urinary pH >7.5. Weak acids are trapped in urine and excreted - haemodialysis = blood is taken out, toxins removed and cleaned and put back into the body - haemoperfusion = method of blood filtration

What is the antidote to benzodiazepines? 1 - flumazanil 2 - glucagon 3 - atropine 4 - naloxone

1 - flumazanil - need to be careful with this - if chronic benzodiazepines are stopped and flumazanil is given, this increases the risk of seizures

What is the antidote to organophosphates? 1 - flumazanil 2 - glucagon 3 - atropine 4 - naloxone

3 - atropine - organophosphates = cholinergic, so we need to give an anti-cholinergic

Which 2 are antidotes to Cyanide, which is common in those exposed to fires? 1 - flumazanil 2 - glucagon 3 - dicobalt edetate 4 - hydroxocobalamin

3 - dicobalt edetate 4 - hydroxocobalamin

What is the antidote to digoxin? 1 - digibind 2 - glucagon 3 - atropine 4 - naloxone

1 - digibind - digoxin inhibits Na+/K+ ATPase - digibind binds and inhibits digoxin

Which of the following is NOT an antidote for calcium channel blockers? 1 - glucagon 2 - calcium 3 - bisoprolol 4 - insulin

3 - bisoprolol

What is the antidote to carbon monoxide? 1 - digibind 2 - glucagon 3 - atropine 4 - methylene blue

4 - methylene blue

What is the antidote to opioids? 1 - digibind 2 - glucagon 3 - atropine 4 - naloxone

4 - naloxone - need to use caution because if the opioid stimulant is abruptly removed they may seizure

What is the antidote to paracetamol? 1 - digibind 2 - glucagon 3 - N-Acetyl cysteine 4 - naloxone

3 - N-Acetyl cysteine - precursor for glutathione

What is the antidote to iron? 1 - digibind 2 - desferrioxamine 3 - N-Acetyl cysteine 4 - naloxone

2 - desferrioxamine

Acetaminophen (paracetamol) is typically metabolised by glucuronidation and sulfation to non-toxic metabolites. However, cytochrome P450 also metabolises acetaminophen into a toxic substance. What is this substance called? 1 - acetaldehyde 2 - azithromycin 3 - N-acetyl-p-benzoquinone imine (NAPQI) 4 - methanol

3 - N-acetyl-p-benzoquinone imine (NAPQI)

Some paracetamol is metabolise by cytochrome P450 into N-acetyl-p-benzoquinone imine (NAPQI). Although this is toxic and can damage the liver, the liver is able to produce what that inactivates NAPQI? 1 - beta-carotene 2 - glutathione 3 - carotenoids 4 - coenzyme Q10

2 - glutathione - in a paracetamol overdoes means lots of NAPQI and there is insufficient glutathione causing liver damage and cell death - in extreme cases it can cause liver failure and death

Patients who take an excess of paracetamol need a blood test to identify the concentration of paracetamol in the blood. When do paracetamol levels peak in the blood? 1 - 30 mins 2 - 60 mins 3 - 2 hours 4 - 4 hours

4 - 4 hours - need to identify when the 4 hours is as this is when treatment needs to be started - antidote is 3 - N-Acetyl cysteine a precursor for glutathione