Overview Questions Flashcards
1
Q
The most common significant, acute clinical effect noted thus far in ACE Inhibitor overdose is:
a.Hyperkalemia secondary to a decrease in aldosterone secretion.
b.Angioedema of the head and neck.
c.Hypotension developing within one hour of exposure.
d.Acute renal failure and nephrotic syndrome.
e.Hepatic dysfunction, usually cholestatic in nature.
A
C - Most commonly seen is a drop in BP.The other symptoms listed are not common at all.
2
Q
Angioedema has been reported with therapeutic use of ACE Inhibitors. All of the statements are true of this condition EXCEPT which of the following:
a.Angioedema is usually present in the head and neck especially the face, lips, tongue and glottis.
b.Initial pharmacological intervention with epinephrine, antihistamines and steroids is recommended but not always effective.
c.If angioedema is unresponsive to pharmacological intervention, oral or nasal intubation may be necessary.
d.Angioedema in the setting of ACE Inhibitor ingestion is believed to be related to a drug allergy and is frequently accompanied by urticaria.
e.Angioedema in the setting of ACE Inhibitor ingestion is believed to be a biochemical reaction related to bradykinins rather than an immunologic response.
A
D - It is well known that drug allergy is NOT the cause of angioedema.
3
Q
Which of the following statements is FALSE concerning observation and treatment during overdose from ACE Inhibitors:
a.Monitor serum electrolytes, especially potassium and sodium.
b.Hemodialysis is expected to be effective in eliminating ACE Inhibitors, but has not been necessary in documented cases thus far.
c.ACE Inhibitor levels correlate well with toxicity by these agents.
d.Monitor hepatic and renal function.
e.Hypotension associated with ACE Inhibitor overdose usually will manifest within one hour of ingestion.
A
C - Patients may remain asymptomatic despite high serum ACE inhibitor drug levels. Serum levels don’t correlate with toxicity.
4
Q
Side effects reported with therapeutic use of the ACE Inhibitors include all of the following EXCEPT: a.Angioedema. b.Respiratory depression. c.Cough. d.Hyperkalemia. e.Hyponatremia.
A
B - PI does not make mention of respiratory depression as a common side effect or symptom.
5
Q
Which of the following clinical manifestations would not be related to acute acetaminophen overdose:
a.metabolic acidosis.
b.hematological changes including thrombocytopenia.
c.seizures.
d.persistent emesis and pancreatitis.
e.renal insufficiency and acute tubular necrosis.
A
C - Neurologic signs and symptoms are rarely seen in APAP overdoses.
6
Q
The Matthew-Rumack nomogram is helpful in assessing the potential risk of acetaminophen overdose and the indication for NAC therapy. Which of the following statements is TRUE concerning the use of the Matthew-Rumack nomogram?
a.Acetaminophen levels exceeding 150 mcg/ml may be used to assess the need for NAC therapy even when drawn before four hours post-exposure. This is based on the fact that any acetaminophen level exceeding this threshold limit indicates the need for NAC therapy.
b.Acetaminophen levels after CHRONIC ingestion cannot be plotted on the nomogram with any accuracy.
c.Do not give NAC until a toxic level has proven the need for the antidote since it may not be discontinued once instituted, under any circumstances.
d.When subsequent acetaminophen levels after an initial toxic four hour level fall into the low risk toxicity range, NAC therapy may be safely withdrawn if liver enzymes are closely monitored on a daily basis.
e.Levels after CHRONIC ingestion may be accurately plotted on the Matthew-Rumack Nomogram when the level is drawn at least four hours after the last dose.
A
B - The R-M nomogram is not designed to evaluate chronic APAP ingestions.
7
Q
Pregnant women ingesting acetaminophen in overdose amounts place the fetus at risk for acetaminophen toxicity. Specifics to consider when assessing these exposures do NOT include:
a.Acetaminophen is known to cross the placenta and fetal liver cells are capable of metabolizing acetaminophen, thus putting the fetus at risk for hepatotoxicity.
b.Fetal blood levels of acetaminophen after maternal overdose have been shown to be equal to that of the mother.
c.NAC, the antidote for acetaminophen overdose, has been shown to undergo placental transfer in pregnant rats, theoretically making it available to the fetus for protection of the liver.
d.Maternal acetaminophen overdose is a definite indication for termination of the pregnancy once the NAC protocol is completed.
e.Rapid treatment of the mother with NAC is the best way to treat the fetus in the setting of acetaminophen toxicity. Delayed treatment, especially in the first trimester, has been associated with the poorest fetal outcomes.
A
D – Administering NAC to the mother as soon as possible after the overdose is the most effective means of preventing hepatotoxicity in mother and fetus
8
Q
Recalcitrant emesis is a troublesome symptom of acetaminophen toxicity in part because it impairs the ability to deliver the NAC antidote orally. Approaches to the management of this problem include all of the following EXCEPT:
a.The institution of an intravenous protocol for NAC therapy.
b.Administration of antiemetics such as ondansetron, metoclopramide, or droperidol as a pretreatment to NAC therapy.
c.Decreasing the dilution of the NAC dose so that a smaller volume of solution will be delivered. Solutions of NAC as high as 10-20% have been instituted with better retention due to the smaller volume.
d.Insertion of a nasogastric tube into the stomach to deliver the dose of NAC over a 30-60 minute period.
e.If emesis continues, the NG tube may be advanced into the duodenum for the delivery of NAC.
A
C - Decreasing the dilution would increase the emesis potential.
9
Q
Late presentation (>24 hours) of the acetaminophen overdose patient poses a multitude of management decisions for the SPI. The following statement is FALSE concerning management considerations in this setting: a.After 24 hours post-ingestion, the interpretation of acetaminophen blood levels is questionable. b.The use of NAC should be strongly considered in late presentation acetaminophen overdose in those patients with detectable acetaminophen levels or biochemical evidence of hepatotoxicity. c.The Matthew-Rumack nomogram may be helpful in assessing late presentation acetaminophen overdoses by plotting the level at the 24 hour mark. d.NAC dosing follows the same dosing protocol for late presentation as for early presentation: A loading dose of 140 mg/kg NAC as a 5% solution, followed by 70mg/kg NAC as a 5% solution at every 4 hour intervals for 17 maintenance doses. e.NAC therapy instituted as late as 36 to 80 hours after acetaminophen ingestion has been shown to improve clinical outcome and survival rates in acetaminophen overdose.
A
C - The R-M nomogram is not helpful in assessing late presenters. Other factors like preexisting conditions, LFTs, PT/INR, etc. would need to be considered.
10
Q
A 3 year old, 30 pound child arrives in ED, tachycardic with heart rate of 170 bpm sinus rhythm, agitated, and nervous. According to mom, the child has ingested 60cc of albuterol sulfate syrup about thirty minutes ago. What lab work would you want to monitor on this child? a.Potassium and glucose levels b.Theophylline level c.Glucose and chloride levels d.Arterial blood gases e.Cardiac enzymes
A
A - Significant decreases in serum potassium can occur following intravenous or oral administration of albuterol in high doses. Hyperglycemia is observed following albuterol administration, with diabetic ketoacidosis occurring in susceptible individuals.
11
Q
Which of the following statements about treatment of albuterol exposures is true?
a.Treatment should begin with IV glucose and bicarbonate administration.
b.Administration of propranolol may be effective in reducing palpitations and associated anxiety.
c.Hemodialysis is an effective treatment in overdose situations.
d.Rinsing the mouth after inhalation of albuterol will decrease the occurrence of muscle tremors in asthmatic patients.
e.Because of the slow absorption rate of liquid albuterol, ipecac would be an effective decontamination agent.
A
B – Administration of propranolol may be helpful in reducing palpitations and anxiety in the patient with an albuterol overdose. Propranolol is contraindicated in patients with bronchial asthma and severe COPD.
12
Q
All of the following symptoms can occur in overdose of sympathomimetics except for: a.Hypertension b.Ischemic EKG changes c.Supraventricular tachycardia d.Pulmonary edema e.Miosis
A
E - Sympathetic stimulation from systemic or ocular exposures to sympathomimetic drugs will usually result in mydriasis not miosis.
13
Q
A nurse administering Brethine (terbutaline) to a patient mistakenly sticks the needle into the tip of her thumb and injects some of the medication. Which of the following statements concerning this exposure is true?
a.Central nervous system depression may occur.
b.Atropine should be given to decrease the tachycardia.
c.Surgical opening of thumb should be attempted to remove any medication in area.
d.Accidental subcutaneous autoinjection of a digit may result in severe vasoconstriction with numbness and paleness.
e.Other than pain at site, no effect is expected.
A
D - Significant vasoconstriction resulting in numbness and paleness of the left index finger occurred following subcutaneous epinephrine autoinjection of the digit.
14
Q
Which of the following statements concerning exposures to albuterol is FALSE?
a.Overdose cases are generally considered to produce symptoms which are extensions of the adverse effect.
b.Patients may have tachycardia or hypertension.
c.Arterial hypoxemia can be exaggerated if albuterol is used in excess.
d.Young children who receive albuterol syrup may experience CNS depression.
e.Significant hypokalemia can occur following intravenous or oral administration of albuterol in high doses.
A
D - Adverse effects include tachycardia, premature ventricular contractions, palpitations, tremor, agitation, nervousness, headache, dizziness, insomnia, hyperglycemia, hypoglycemia, nausea, and vomiting.
15
Q
1.Amphetamine overdose is LEAST likely to cause which of the following toxic manifestations? a.Tachycardia b.Seizures c.Hypotension d.Mydriasis e.Hyperthermia
A
1.C - Systolic and diastolic hypertension are common and may be postural.
16
Q
2.Which of the following laboratory tests is likely to be of LEAST value in assessing the symptomatic patient following an amphetamine overdose? a.CPK b.Liver enzymes c.Renal function tests d.Amphetamine levels e.Serum electrolytes
A
2.D - Most members of the amphetamine family and related diet pill constituents are difficult to detect in the plasma unless very large amounts have been ingested, as in chronic abusers.
17
Q
3.Acidification of the urine is not recommended following overdose of amphetamines because it may precipitate: a.Renal failure b.Seizures c.Hallucinations d.Liver failure e.Ascites
A
3.A - Acidification enhances amphetamine excretion but may precipitate acute renal failure in patients with myoglobinuria and is CONTRAINDICATED.
18
Q
4.Which of the following is used as a street name for methamphetamines? a.“Crank” b.“Speed” c.“Ice” d.“Meth” e.All of the above
A
4.E - SLANG TERMS associated with methamphetamine: “speed,” “crystal,” “crank,” “meth,” and “ice”.
19
Q
1.Of the antibiotics used today, which group is most commonly associated with causing drug induced renal failure? a.Penicillin b.Cephalosporins c.Tetracyclines d.Aminoglycosides e.Sulfonamides
A
D – aminoglycosides. Rationale: “The incidence of nephrotoxicity post treatment with aminoglycoside antibiotics is estimated to be 5 – 100%” Goldfrank’s, 1998, pg 759.
Examples:
gentamicin, tobramycin, amikacin, plazomicin, streptomycin, neomycin, and paromomycin
20
Q
.The combination of which of the following antibiotics and ethanol may produce a disulfiram-type reaction? a.Gentamicin b.Metronidazole c.Amoxicillian d.Erythromycin e.Ampicillin
A
B – metronidazole (Flagyl). Rationale: Per Drugdex®, some persons taking metronidazole experience disulfiram-like reactions when using alcohol. Probable mechanism inhibition of acetaldehyde metabolism.
21
Q
3.A 2-year-old child weighing 14 kg ingested two ounces of his amoxicillin 250mg/5ml suspension. Which of the following is the most appropriate recommendation?
a.Dilute and observe in the home setting
b.Multiple dose activated charcoal
c.Whole bowel irrigation
d.Hemodialysis
e.Gastric lavage
A
3.A –dilute and observe in the home setting.
22
Q
1.A lengthening of the prothrombin time is commonly seen with an overdose of warfarin. This lengthening may be evident within \_\_\_ hours of the exposure and peak in \_\_\_ hours. a.6 hours/24 hours b.12 hours/24 hours c.24 hours/36-72 hours d.36 hours/144 hours e.48 hours/144 hours
A
1.C. - 24 hours/36-72 hours. This correlates with the half life of factor VII.
23
Q
2.Warfarin and related compounds interfere with clotting factor synthesis by blocking the vitamin K- dependent gamma-carboxylation of glutamic acid residues in precursors of all of the following clotting factors EXCEPT: a.II b.III c.VII d.IX e.X
A
2.B – III
Warfarin and warfarin-like oral anticoagulants mechanism of action involves Vitamin K inhibition. Vitamin K is a cofactor in the postribosomal synthesis of clotting factors II, VII, IX and X.
24
Q
3.The initial treatment of choice for a patient with active blood loss after an overdose of a long acting anticoagulant would be: a.Activated charcoal b.Fresh frozen plasma c.Menadione d.Menadiol e.Observation
A
3.B – fresh frozen plasma.
25
4. All of the following statements are true in regards to an overdose of a long acting anticoagulant EXCEPT:
a. Bleeding may be the first manifestation of toxicity.
b. The diagnosis is typically an easy diagnosis, if there is a history of exposure.
c. Anticoagulant effects of warfarin can be expected to disappear within a few days; reports concerning human exposures to brodifacoum have been associated with clinical bleeding for more than 6 months.
d. Slow systemic clearance and a large volume of distribution may explain brodifacoum’s prolonged effect.
e. Administration of vitamin K1 as antidote to anticoagulant poisoning is NOT effective.
D – brodifacoum: Vd = 0.985L/Kg in rats.
26
1. Gabapentin is an antiepileptic drug indicated as an adjunct to current antiepileptic therapy in adults. All of the following are true statements EXCEPT:
a. The mechanism of action of gabapentin remains unknown.
b. Peak plasma concentrations occur 2-4 hours after ingestion.
c. Gabapentin binds to the plasma proteins and is metabolized by the liver.
d. Gabapentin is primarily excreted by the kidneys as unchanged drug.
e. Gabapentin is a well-tolerated antiepileptic agent that has some mild CNS effects.
1. D - Gabapentin is not metabolized and is excreted unchanged by the kidneys
27
2. Which of the following statements about phenytoin is CORRECT:
a. At plasma concentrations below 10mg/L, elimination is linear (first order).
b. At plasma concentrations below 10mg/L, elimination is zero order.
c. At plasma concentrations below 10mg/L, elimination is second order.
d. At plasma concentrations below 10mg/L, elimination is by Michaelis-Menten kinetics.
e. At plasma concentrations below 10mg/L, elimination is totally by the kidneys.
A - At therapeutic levels, elimination is first-order. In an overdose, saturation of the hepatic hydroxylation system may occur and result in elimination following Michaelis-Menten kinetics. A prolonged half-life is the result when this occurs.
28
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3. Which of the following is NOT likely to be seen with an oral overdose of phenytoin?
a. Nystagmus
b. Ataxia
c. Dysrhythmias
d. CNS depression
e. Vomiting
```
3. C – Cardiotoxicity is unlikely following an oral overdose of phenytoin. Cardiotoxicity HAS been reported following the IV administration of both phenytoin and fosphenytoin.
* SEVERE TOXICITY: Large oral ingestions can cause more severe CNS depression, coma, and, rarely, respiratory depression. Rapid infusion of the parenteral formulation (faster than 50 mg/min) can cause hypotension, bradycardia, AV conduction delays, and ventricular dysrhythmias which may be fatal. It is felt that the cardiotoxicity of the intravenous formulation of phenytoin is secondary to the diluent, propylene glycol, and not the phenytoin itself.
29
1. A 182 pound male was just admitted to a rural hospital ICU following an acetaminophen overdose 12 hours earlier. The attending physician wrote orders for Mucomyst to be given. The nurse caring for this patient calls the poison center for information on how much Mucomyst she should be dosing. All she knows is that she can obtain a 20% solution from the pharmacy. For this patient, what are the loading dose and maintenance doses she will need to give?
a. 127 cc loading dose, 64 cc maintenance dose
b. 58 cc loading dose, 58 cc maintenance dose
c. 58 cc loading dose, 29 cc maintenance dose
d. 65 cc loading dose, 32 cc maintenance dose
e. 127 cc loading dose, 127 cc maintenance dose
1. C – Dosing for NAC therapy is 140 mg/kg loading dose, followed by maintenance doses of 70 mg/kg. This patient weighs 82.7 kg, so the loading dose would be 11,582 mg and maintenance doses would be 5,792 mg. 20% Mucomyst contains 200 mg/ml (20% equals 20 grams per 100ml). Divide the dose required by the concentration of the solution to get the volume of drug needed.
30
2. A child was exposed to his mother’s prenatal iron tablets. In the ED, the stomach was emptied, and a serum iron concentration drawn 3 hours after the ingestion was 358 mcg/ml. The child was vomiting, drowsy, and had an arterial pH of 7.24. The physician ordered deferoxamine to be given. Which of the following statements concerning deferoxamine therapy is CORRECT?
a. The indication for deferoxamine is when the SI is greater than the TIBC
b. The dose is 15 mg/kg deep IM every 4 hours until the urine changes color
c. Deferoxamine 15mg/kg/hr IV for 72 hours for SI levels greater than 350 mcg/ml
d. Sepsis has been associated with the administration of deferoxamine
e. Deferoxamine therapy must be given IM to avoid venous infiltration
D – Yersinia enterocolitica septicemia has been associated with the administration of deferoxamine in iron-overdosed children.
31
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3. The chelator dimercaprol (BAL) is FDA approved for toxic exposures to which of the following?
a. Lead, iron and cadmium
b. Arsenic, gold and mercury
c. Arsenic, mercury and uranium
d. Lead, copper and iron
e. Mercury, gold and selenium
```
3. B -- Arsenic, gold and mercury.
Dimercaprol (BAL) is also FDA approved for the treatment of lead poisoning.
32
4. A patient having attempted suicide with captopril is in the ED, being decontaminated. The MD calls the poison center for the name of the appropriate antidote. What course of action would the specialist recommend?
a. You advise the physician that calcium is the physiological antagonist to increase myocardial contractility.
b. You advise the physician that administration of glucagon would be an appropriate therapy for this patient.
c. You advise the physician that flumazenil is the drug of choice for symptoms of CNS depression and hypotension.
d. You advise the physician that this is always a nontoxic ingestion and no therapy is indicated.
e. You advise the physician that they should monitor for hypotension, and manage with Trendelenburg position and IV fluids.
4. E – ACE inhibitors generally cause mild hypotension that can usually be treated with IV fluids and positioning.
Examples:
Capoten (captopril) Vasotec (enalapril) Prinivil, Zestril (lisinopril) Lotensin (benazepril)
33
5. Which statement concerning the use of antidotes is INCORRECT?
a. Flumazenil may be of utility in the treatment of benzodiazepine overdose, although seizures may occur if a tricyclic antidepressant has been co-ingested
b. The “Universal Antidote” consisting of burned toast, strong tea, and Milk of Magnesia serves no purpose in modern day toxicology.
c. Glucose, naloxone, and oxygen should be considered for any patient who is found unresponsive in the absence of a known toxin.
d. Pralidoxime is of greatest utility in the treatment of poisonings due to pyrethroid insecticides.
e. Digibind (FAB) is indicated for rhythm and conduction disturbances, refractory hyperkalemia, and digoxin level 10-15 ng/ml in acute ingestions.
5. D – Pralidoxime is used in the treatment of organophosphate poisonings.
34
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1. Which of the following drugs should be avoided when treating dysrhythmias associated with an overdose of procainamide?
a. Sodium bicarbonate
b. Lidocaine
c. Quinidine
d. Magnesium sulfate
e. Isoproterenol
```
1. C – Quinidine. Quinidine is a class Ia antiarrhythmic, as is procainamide. Co-administration may result in further prolongation of the QT interval and induce torsades de pointes.
Note: Procainamide --
Class Ia antiarrhythmic; sodium channel blocker
35
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2. Which of the following medications does NOT have a potentially major interaction with quinidine that could result in toxicity?
a. Acetazolamide
b. Clarithromycin
c. Digoxin
d. Disulfiram
e. Itraconazole
```
2. D – Disulfiram. Disulfiram has not been shown to have an interaction with quinidine. Acetazolamide decreases the clearance of quinidine, while clarithromycin and itraconazole decrease the metabolism resulting in potentially toxic levels. Co-administration of digoxin and quinidine may result in significantly increased digoxin levels and resultant toxicity.
36
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1. Which of the following drugs would be most appropriate for initial control of seizures caused by a toxic ingestion of an antihistamine?
a. Phenobarbital
b. Diazepam
c. Fosphenytoin
d. Gabapentin
e. Valproic acid
```
1. B – Diazepam. Benzodiazepines are the initial therapy of choice for control of seizures in this instance. Phenobarbital should be considered for refractory or recurrent seizures. Benzodiazepines and barbiturates are generally preferred over phenytoin or fosphenytoin for the control of drug-induced seizures.
37
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2. Which of the following antihistamines is LEAST likely to cause CNS depression when taken in overdose?
a. Hydroxyzine
b. Diphenhydramine
c. Promethazine
d. Loratadine
e. Clemastine
```
2. D – Loratadine.
Loratadine has a low incidence of CNS depression. All other choices have a moderate to high incidence.
38
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1. A drug which may be used to increase blood pressure and heart rate in both calcium channel blocker and beta adrenergic blocker overdose is:
a. Procainamide
b. Sodium nitroprusside
c. Hydralazine
d. Glucagon
e. Nitroglycerin
```
1. D - Glucagon produces positive inotropic, chronotropic and dromotropic effects. It may be used to increase blood pressure and heart rate in both calcium channel blocker and beta adrenergic blocker overdose.
39
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2. A patient who is a victim of clonidine overdose may have symptoms that mimic those in a patient who has overdosed on which of the following classes of drugs?
a. Opiates
b. MAO inhibitors
c. Amphetamines
d. Salicylates
e. ACE inhibitors
```
2. A - Clonidine is a centrally acting adrenergic inhibitor that stimulates alpha 2 adrenergic presympathic (inhibitory) receptors in the brain. Toxic effects resemble opiate like toxicity with generalized CNS depression. Naloxone may be useful in reversing the effects although it has not always produced consistent effects.
40
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3. Hypokalemia would be most commonly associated with overdose due to:
a. Digoxin
b. Propranolol
c. Hydrochlorothiazide
d. Captopril
e. Clonidine
```
3. C - Hydrochlorothiazide is a thiazide diuretic which causes hypokalemia.
41
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4. A patient who has overdosed on an unknown quantity of sustained release verapamil 240mg tablets has been lavaged, yet numerous tablets can still be visualized on an abdominal X-ray. Which of the following should be considered?
a. Peritoneal dialysis
b. Hemodialysis
c. Whole bowel irrigation
d. Charcoal hemoperfusion
e. Exchange transfusion
```
4. C - Whole bowel irrigation. This may be useful in sustained release calcium channel blocker overdoses if visualized on abdominal x ray.
Examples:
Amlodipine (Norvasc) Diltiazem (Cardizem, Tiazac, others) Felodipine. Isradipine. Nicardipine. Nifedipine (Adalat CC, Procardia) Nisoldipine (Sular) Verapamil (Calan, Verelan)
42
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5. Bronchospasm may be induced in the asthmatic patient who has taken an overdose of:
a. Clonidine
b. Verapamil
c. Nifedipine
d. Furosemide
e. Propranolol
```
5. E - Propranolol is a non-specific beta blocker which may produce bronchospasms in patients with asthma or bronchospastic disease because it blocks B receptors in the lungs.
43
```
1. Blindness is a toxic effect most commonly associated with which of the following?
a. Digoxin
b. Theophylline
c. Quinine
d. Colchicine
e. Lithium
```
1. C – Quinine has a direct toxic effect on photoreceptor and ganglion cells in the retina that can produce blurred vision impaired color perception, constriction of visual fields and permanent blindness in some patients.
44
```
2. Early signs and symptoms of quinine poisoning may be mistaken for toxicity due to :
a. Acetaminophen
b. Propranolol
c. Diltiazem
d. Aspirin
e. Amitriptyline
```
2. D - Aspirin – quinine may produce nausea, vomiting, and “cinchonism” {tinnitus, deafness, vertigo, headache, and visual disturbances} which resemble aspirin toxicity.
45
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3. Of the following, the best choice in the treatment of cardiac conduction defects associated with quinine poisoning is:
a. Sodium bicarbonate
b. Quinidine
c. Procainamide
d. Bretylium
e. Disopyramide
```
3. A - Sodium bicarbonate – the sodium ion and alkalemia produced reverses the sodium channel dependent membrane depressant “quindine” like effects.
46
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4. Enhanced elimination of quinine following an overdose would best be accomplished through the use of:
a. Hemodialysis
b. Peritoneal dialysis
c. Charcoal hemoperfusion
d. Multiple dose activated charcoal
e. Forced alkaline diuresis
```
4. D - Multiple dose activated charcoal (MDAC) may be beneficial according to the latest position statement for MDAC. Other substances MDAC are useful include phenobarbital, dapsone, theophylline and carbamazepine.
47
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5. Which of the following is most likely to be effected in the patient with severe chloroquine poisoning, and therefore requires careful monitoring?
a. Sodium
b. Potassium
c. Magnesium
d. Chloride
e. Glucose
```
5. B – Chloroquine overdose may produce severe hypokalemia which can cause arrhythmias.
48
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1. Which of the following should be administered following an overdose of methotrexate?
a. Sodium nitrite
b. Leucovorin
c. Physostigmine
d. Thiamine
e. Pralidoxime
```
1. B - Leucovorin (citrovorum factor, folinic acid): Eliminates the hematopoietic toxicity by supplying the necessary tetrahydrofolate co-factor, the synthesis of which is blocked by methotrexate
49
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2. A medication which is helpful in reducing the renal toxicity of cyclophosphamide is:
a. Leucovorin
b. Amifostine
c. Calcium sulfate
d. Mesna
e. Mannitol
```
2. D - Cyclophosphamide-induced incidence and severity of hematuria can be significantly reduced by vigorous hydration, a fractionated dose schedule, and a protector such as Mesna
50
```
3. The appropriate initial intervention in extravasation of an infusion of doxorubicin is:
a. Apply a heating pad
b. Elevate the site
c. Stop the infusion
d. Apply a constricting band
e. Apply topical steroids
```
3. C - Doxorubicin is a tissue irritant. Should extravasation occur, stop flow of doxorubicin at site immediately.
51
```
4. What organ system is most likely to be affected following an overdose of cisplatin?
a. Pulmonary
b. Cardiovascular
c. Hepatic
d. Renal
e. Nervous
```
4. D - Nephrotoxicity is a dose-limiting toxicity associated with cisplatin therapy. When nephrotoxicity is controlled, nausea and vomiting and neurotoxicity become the dose-limiting toxicities of cisplatin therapy.
52
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5. A bottle of paclitaxel has been dropped on the floor and broken. The most appropriate initial intervention is:
a. Neutralize with household bleach
b. Contain the spill
c. Notify OSHA immediately
d. Locate the MSDS
e. Open all windows in room
```
5. B - The mutagenic and carcinogenic potential of many antineoplastic agents is well established and may present a possible health hazard for individuals handling these agents, any spill should be contained quickly.
53
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1. Ingestion of a mouthful of hydrogen peroxide 3% in an adult is most appropriately treated by:
a. Gastric lavage
b. Dilution with water
c. Administration of ipecac
d. Administration of activated charcoal
e. Administration of antacids
```
1. B - Three percent hydrogen peroxide is low potential for toxicity and most treatment needed for ingestion would be to dilute with water.
54
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2. Isopropyl alcohol is converted via metabolism to:
a. Acetone
b. Ethanol
c. Formaldehyde
d. Oxalic acid
e. Methanol
```
2. A - Isopropyl alcohol is slowly metabolized to acetone. Acetone is metabolized to acetate, formate, and carbon dioxide.
55
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3. The corrosive effects, which may be seen with ingestion of an iodine tincture, may be minimized by:
a. Lavage with potassium permanganate
b. Administration of n-acetylcysteine
c. Administration of activated charcoal
d. Induction of emesis
e. Having patient eat starchy food
```
3. E - The presence of food in the stomach inactivates iodine by converting it to iodide which is relatively innocuous. A blue colored emesis indicates the presence of food (starch) in the stomach and the conversion of iodine to iodide.
56
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4. Other than the pine oil itself, what ingredient in most Pine Oil Cleaners could potentially cause toxicity if a toddler consumes a significant amount of the product.
a. Isopropyl alcohol
b. Ethanol
c. Wintergreen
d. Ethylene glycol
e. Anionic detergents
```
4. A - Pine oil cleaners may contain isopropyl alcohol 5-10% and if significant ingestion occurs could potentially cause toxicity in a toddler.
57
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5. The combination of household bleach (sodium hypochlorite) and household ammonia will produce:
a. Carbon dioxide
b. Chloramine gas
c. Hydrogen chloride
d. Chlorine gas
e. Chloroform
```
5. B - When bleach (sodium hypochlorite) and ammonia are combined, the mixture produces a chloramine gas.
58
```
1. Acute isoniazid (TB medication) overdose is most commonly associated with which of the following adverse effects?
a. Hypertension
b. Metabolic alkalosis
c. Respiratory depression
d. Seizures
e. Hypoglycemia
```
1. D - Seizures
Other symptoms are not typical of isoniazid overdose
59
```
2. Treatment of poisoning due to isoniazid involves which of the following antidotes?
a. Phentolamine
b. Pyridoxine
c. Physostigmine
d. Phytonadione
e. Pralidoxime
```
2. B – Pyridoxine is the initial agent of choice for the treatment of INH seizures
60
```
3. Which of the following antituberculous drugs is most likely to cause metabolic acidosis when taken in overdose?
a. Rifampin
b. Pyrazinamide
c. Isoniazid
d. Ethambutol
e. Streptomycin
```
3 C - Isoniazid
None of the others cause acidosis
61
```
4. Early management of intoxication due to isoniazid does NOT involve:
a. Induction of emesis
b. Establishment of an IV line
c. Administration of activated charcoal
d. Protection of airway
e. Assessment of circulatory status
```
4. A - Emesis not a suggested treatment due to the possible rapid onset of seizures.
62
```
5. Which of the following adverse effects is most likely to be seen in the patient treated with rifampin (TB antibiotic)?
a. Hepatitis
b. Cardiomyopathy
c. Exfoliative dermatitis
d. Hypocalcemia
e. Pulmonary edema
```
5. A - A possible side effect of chronic therapy. Rifampin can cause transient elevations in hepatic enzymes usually within the first 8 weeks of therapy in 10% to 15% of patients, with less than 1% of the patients demonstrating overt rifampin-induced hepatotoxicity. The occurrence of mortality associated with hepatotoxicity has been reported to be 16 in 500,000 patients receiving rifampin.
63
```
1. Which of the following antidotes is most appropriate for the treatment of acute arsenic toxicity?
a. Pralidoxime
b. BAL
c. Atropine
d. N-acetylcysteine
e. Deferoxamine
```
1. B - BAL
Other answers are antidotes for other toxins
64
```
2. The most appropriate specimen to assist in the assessment of the degree of arsenic poisoning is:
a. Whole blood
b. Hair and nails
c. Stomach contents
d. 24-hour urine collection
e. Feces
```
2. D - 24-hour urine collection is the best way to check
65
```
3. The most common early symptom of acute arsenic poisoning is:
a. Pulmonary edema
b. Peripheral neuropathy
c. Gastroenteritis
d. Seizures
e. Fever
```
3. C – Gastritis
Nausea, vomiting and diarrhea are the symptoms most frequently noted with arsenic toxicity.
66
```
4. The breath and feces of a person who has been exposed to arsenic compounds may have a characteristic odor, which may aid in diagnosis. This smell is best characterized as:
a. Fish
b. Garlic
c. Ammonia
d. Vinegar
e. Rotten eggs
```
4. B – Arsenic has often been described as having the smell of garlic
67
```
5. Which of the following organ systems are affected by arsenic toxicity?
a. Gastrointestinal
b. Central nervous system
c. Renal
d. Hematologic
e. All of the above
```
5. E – Arsenic has toxic effects on all of these systems
68
```
1. The ingestion of a ceramic glaze would most likely result in toxicity due to which of the following metals?
a. Bismuth
b. Antimony
c. Lead
d. Copper
e. Arsenic
```
1. C – Lead is the most common heavy metal found in ceramic glazes
69
```
2. The toxic metal most frequently found in yellow oil paints is:
a. Cadmium
b. Barium
c. Ithium
d. Molybdenum
e. Strontium
```
2. A – Cadmium yellow oil paint contains high percentages of various cadmium compounds
70
```
3. The mother of a child who has ingested a small amount (approximately 1/2 teaspoon) of glitter calls the poison center. The child is asymptomatic. The most appropriate therapy would be:
a. Syrup of ipecac
b. Gastric lavage
c. Activated charcoal
d. Whole bowel irrigation
e. Observation only
```
3. E – This child would not be expected to develop toxicity due to this exposure. The glitter would not be absorbed, and should pass uneventfully.
71
4. Art supplies labeled "CP Non-Toxic":
a. Are made from only non-toxic materials
b. Do not contain materials in sufficient quantities to harm humans
c. Are tested by the Food and Drug Administration
d. Must be manufactured in the United States
e. Are still likely to be of harm with chronic use
4. B – Products bearing the CP non-toxic label have been certified by the Art & Creative Materials Institute (ACMI) to contain no ingredients in sufficient quantities to be toxic or injurious to humans.
72
```
5. An artist who creates metal sculptures with a welding torch is most likely to develop which of the following as a result of his craft?
a. Silicosis
b. Cardiomyopathy
c. Agranulocytosis
d. Metal fume fever
e. Renal tubular necrosis
```
5. D – Metal fume fever is frequently seen in welders, particularly those who are working with galvanized metal in poorly ventilated areas.
S/S:
Influenza type symptoms - a raised temperature, chills, aches and pains, nausea and dizziness. It is caused by exposure to the fume of certain metals - commonly zinc
73
1. Which of the following statements concerning hymenoptera envenomation is FALSE:
a. Honey bee stingers are barbed and remain in the victim.
b. Symptoms usually resolve within a few hours.
c. Hypersensitivity reactions to venom allergens are dose-dependent.
d. Those who have had an anaphylactic reaction have approximately a 50% chance of developing the same reaction with subsequent stings.
e. Diphenhydramine and steroids are treatment options for allergic reactions to envenomations.
1. C – Hypersensitivity reactions to venom allergens are dose-dependent = FALSE
A single sting may cause an anaphylactic reaction in a sensitive individual.
74
```
2. The following are symptoms of an envenomation by a Black Widow spider EXCEPT:
a. Abdominal pain
b. Muscle fasiculations
c. Tachycardia
d. Constipation
e. Hyptertension
```
2. D – Constipation is not an expected effect following black widow envenomation. Gastrointestinal symptoms that may be seen include nausea, vomiting, excessive salivation, and abdominal pain.
75
3 The most appropriate indication for Black Widow antivenin is:
a. A 75 year-old with chest pain and hypertension
b. A 6 year-old child with leg pain
c. A 35 year-old with tachycardia
d. A 19 year-old with vomiting and paresthesias
e. A 15 year-old with a positive skin test
3. A – Antivenin is indicated in the presence of severe systemic symptoms, in high risk patients, and in patients whose pain is not controlled by opioids and muscle relaxants.
76
4. All of the following are false concerning scorpion envenomation EXCEPT:
a. All United States scorpion stings require an evaluation at an emergency department
b. The Centruroides antivenin is available at any zoo
c. Symptoms are a result of depolarization of nerves and muscles as a consequence of effects in calcium ion channels
d. Rhabdomyolysis is usually a complication of scorpion stings
e. Common stinging scorpions in the US are members of the genera Vejovis, Hadrurus, Androctonus, and Centruroides
4. E – The scorpions listed are the most common species found in the US.
Vejovis (Stripedtail Scorpion, Southern Devil), Hadrurus, Androctonus, and Centruroides (bark scorpion)
77
5. Which of the following statements is NOT true concerning ant envenomations:
a. Characteristically one would see wheal, erythema, and edema, as well as considerable pain.
b. Deaths have been due to either allergic reactions or to massive numbers of stings.
c. The fire ant has a necrotizing toxin similar to that of the brown recluse spider.
d. The fire ant stings very quickly producing immediate pain.
e. Ants may have stingers or may bite with their mandibles and spray a toxic substance into the wound created by their jaws.
5. D – The fire ant stings very quickly producing immediate pain.
Actually, fire ants sting slowly, and inject their venom over seconds to minutes. Their stings are not usually immediately painful.
78
```
1. Which of the following is NOT an expected clinical effect from a toxic ingestion of phenobarbital?
a. Coma
b. Hypertension
c. Nystagmus
d. Respiratory arrest
e. Skin bullae
```
1. B – Hypotension, rather than hypertension, would be expected in the presence of a barbiturate overdose.
79
```
2. Multiple-dose activated charcoal would be most appropriate in the treatment of an overdose of which of the following barbiturates?
a. Butalbital
b. Thiopental
c. Phenobarbital
d. Secobarbital
e. Methohexital
```
2. C – Phenobarbital is a long-acting barbiturate. All of the others are ultra-short or short-acting.
80
```
3. Which of the following should NEVER be recommended for treating a toxic ingestion of a barbiturate?
a. Hemodialysis
b. Alkalinization of the urine
c. Hemoperfusion
d. Activated charcoal
e. Ipecac syrup
```
3. E – Ipecac is contraindicated due to the potential for rapid onset of CNS depression.
81
```
4. Which drug has the shortest duration of clinical effects?
a. Primidone
b. Mephobarbital
c. Secobarbital
d. Phenobarbital
e. Metharbital
```
4. C – Secobarbital is a short-acting barbiturate. All of the others are long-acting.
82
```
1. Which of the following is NOT likely to be contained in a disk battery?
a. Barium
b. Lithium
c. Potassium hydroxide
d. Mercury
e. Manganese dioxide
```
1. A – Barium is not a typical component. All of the other choices are commonly found in button batteries.
83
```
2. Button batteries lodged in the esophagus require:
a. Administration of activated charcoal
b. Gastric lavage
c. Endoscopic removal
d. Whole bowel irrigation
e. Induction of emesis
```
2. C – Batteries lodged in the esophagus require emergent endoscopic removal.
84
3. Radiographic visualization is required following ingestion of a button battery to ensure that:
a. The battery has not lodged in the esophagus.
b. The battery has not cracked or split.
c. The battery is less than 5 mm in diameter.
d. The battery does not contain any sharp edges.
e. The battery does not contain any radioactive compounds.
3. A – Patients with batteries that have passed beyond the esophagus may be sent home and instructed to watch for GI symptoms or fever.
85
```
4. Symptoms to watch for following the ingestion of a button battery include:
a. Vomiting
b. Bloody stools
c. Fever
d. Abdominal pain
e. All of the above
```
4. E – Any or all of these symptoms may be associated with complications due to ingestion of a button battery.
86
5. Following ingestion of a button battery, the patient should be:
a. Hospitalized until the battery has passed entirely through the gastrointestinal tract.
b. Placed on a liquid diet until the battery has passed into the small intestine.
c. Asked to come in for X-ray visualization every 24 hours until passage.
d. Instructed to strain all stools to examine for the presence of the battery.
e. Administered sorbitol every six hours in an attempt to increase transit time.
5. D – Once radiographic visualization has demonstrated that the battery has passed beyond the esophagus, the patient may be managed at home with a normal activity level and diet. Stools should be strained to ensure that the battery has passed.
87
1. Treatment of a pure benzodiazepine overdose is best accomplished by:
a. Supportive care
b. Hemodialysis
c. Intubation and mechanical ventilation
d. Forced diuresis
e. Immediate administration of flumazenil
1. A - Benzodiazepines are generally of a low order of toxicity. Supportive care is often all that is necessary.
88
```
2. Which drug is more likely to cause respiratory arrest following toxic ingestion?
a. Clonazepam
b. Chlordiazepoxide
c. Flunitrazepam
d. Diazepam
e. Lorazepam
```
2. C - Generally, benzodiazepines do not cause respiratory arrest unless combined with another depressant such as alcohol. Flunitrazepam, however, has been reported to cause respiratory arrest when taken alone.
89
```
3. Which of the following benzodiazepines has the longest half-life?
a. Alprazolam
b. Diazepam
c. Flunitrazepam
d. Lorazepam
e. Triazolam
```
3. B - Diazepam.
The parent compound diazepam has a half-life ranging from 20 to 80 hours.
90
4. Which statement about flumazenil is NOT TRUE?
a. It is a specific benzodiazepine receptor antagonist.
b. It may induce acute withdrawal in patients who are addicted to benzodiazepines.
c. It may induce seizures in patients with tricyclic antidepressant overdose.
d. Resedation may occur within 1-2 hours of administration, and repeated dosing is usually required.
e. It is administered intravenously with an initial dose of 2-3 mg.
4. E - The initial dose for a benzodiazepine overdose is 0.2 mg given IV over 30 seconds, with an additional 0.3mg given over 30 seconds if an adequate level of consciousness has not been achieved.
91
```
5. The most frequent clinical effect following diazepam overdose is:
a. Central nervous system depression
b. Respiratory depression
c. Hypothermia
d. Hypotension
e. Bradycardia
```
5. A - The effects of the benzodiazepines can be attributed to effects on GABA, an inhibitory neurotransmitter in the CNS.
92
```
1. Which one of the following beta-blockers is most associated with seizures in toxicity?
a. Atenolol
b. Naldolol
c. Esmolol
d. Propanolol
e. Sotalol
```
1. D - From data collected from overdoses, seizures are far more common following overdose with propranolol.
93
```
2. Beta-blocker toxicity is not associated with which one of the following?
a. Bradycardia
b. AV nodal block
c. Hyperglycemia
d. Hypotension
e. CNS depression
```
2. C - Hypoglycemia may be noted, especially in children or people who are fasting or dieting, or are diabetic.
94
```
3. Which one of the following methods of GI decontamination is contraindicated in beta-blocker toxicity?
a. Ipecac
b. Lavage
c. Activated charcoal
d. Cathartic
e. Hemodialysis
```
3. A - Emesis would be contraindicated in this situation due to the time to emesis with ipecac and the fact that the beta-blocker drugs can cause CNS depression, cardiovascular abnormalities, and seizures.
95
```
4. Which one of the following therapies is not indicated in beta-blocker toxicity?
a. Glucagon
b. Dopamine
c. Atropine
d. Digoxin
e. Ventricular pacing
```
4. D - Digoxin, a cardiac glycoside, would definitely not be indicated in the treatment of beta-blocker toxicity. It is used to treat congestive heart failure and in the treatment of atrial fibrillation or flutter. The drug has a very narrow therapeutic index with a high incidence of severe toxicity.
96
```
5. In addition to the cardiovascular system, beta blockers may block beta receptors in which of the following organ systems?
a. Central nervous system
b. Renal
c. Hepatic
d. Respiratory
e. Endocrine
```
5. D – Beta blockers, particularly those with both beta-1 and beta-2 activity, may cause bronchospasm.
97
Botulism:
1. The best description of botulism is
a. Food borne infection with Clostridium botulinum
b. Sudden onset of spastic paralysis of the limbs but with normal sensation
c. Sudden onset of spastic paralysis of the limbs with paresthesias
d. Neurotoxic flaccid paralysis that always starts with muscles in the face
e. Crying illness that incubates 2 to 3 months
1. D - Botulism is a rare but serious neuroparalytic illness characterized by symmetric, descending flaccid paralysis of motor and autonomic nerves, always beginning with the cranial nerves. The etiologic agent is a potent neurotoxin produced from Clostridium botulinum, an anaerobic, spore-forming bacterium.
There are three main kinds of botulism:
1. Foodborne botulism follows ingestion of preformed toxin produced in food by C. botulinum. The most frequent source is home-canned foods, prepared in an unsafe manner. Other sources have included homemade salsa, baked potatoes cooked in aluminum foil, cheese sauce, garlic in oil, and traditionally prepared salted or fermented fish in Alaska.
2. Wound botulism occurs when C. botulinum spores germinate within wounds. Drug abusers injecting black tar heroin are at increased risk.
3. Infant botulism occurs when C. botulinum spores germinate and produce toxin in the gastrointestinal tract of infants
98
2. Classic early symptoms of foodborne botulism include
a. Double vision
b. Vomiting and/or diarrhea
c. Intense headache and stiff neck
d. Constipation
e. Paresthesias in feet and hands
2. A - The classic symptoms of botulism include double vision, blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, and muscle weakness. Infants with botulism appear lethargic, feed poorly, are constipated, and have a weak cry and poor muscle tone. If untreated, the illness might progress to cause descending paralysis of respiratory muscles, arms and legs. After several weeks, the paralysis slowly improves. In foodborne botulism, symptoms generally begin 18 to 36 hours after eating a contaminated food, but they can occur as early as 6 hours or as late as 10 days. Botulism can result in death due to respiratory failure. However, in the past 50 years the proportion of patients with botulism who die has fallen from about 50% to 8%. Patients who survive an episode of botulism poisoning may have fatigue and shortness of breath for years after the acute illness
99
3. In addition to intensive supportive care, treatment for severe cases may include
a. Barbiturate coma to protect the CNS
b. Antibiotics active against C. botulinum
c. Antitoxin obtained from the CDC
d. Vaccination against subsequent intoxications
e. Antiseizure medications
3. C - Botulinum antitoxin (supplied by CDC) blocks the action of circulating toxin and can prevent progression of illness and shorten symptoms in severe botulism cases if administered early.
100
1. The primary target organ of acute cadmium exposure is the
a. Bone marrow
b. Kidney
c. Liver
d. Lung
e. Bones
1. D - Lungs
Most cadmium health risk stems from chronic exposure to environmental contamination, cigarette smoking, and work in industries handling cadmium. However, inhalation of cadmium fumes, such as those that form during welding, is a source of acute toxic exposure. Metal fume fever is a relatively benign occurrence following inhalation of metal oxide fumes from high heat work with various metals, especially zinc. However, cadmium fumes can cause a serious pneumonitis in addition to metal fume fever. Anyone working galvanized metal (zinc coated) may have some risk of cadmium exposure also since cadmium frequently contaminates zinc ore.
101
2. The primary target organ of chronic cadmium exposure is the
a. Bone marrow
b. Kidney
c. Liver
d. Lung
e. Bones
2. B - The target organ of chronic exposure is the kidney. Cadmium is bound to a protein called metallothionein in the renal tubule cells; its half life of elimination is about 10 years. Since cadmium exposure is ongoing, cadmium bioaccumulates within the kidney during a lifetime. When the capacity of the tubule cells is exceeded, free cadmium is released and damages the cell. Itai itai (“ouch ouch” ) is an end stage disease in Japanese who ate rice grown in grossly contaminated paddies. The “ouch” is bone pain, that occurs not from primary pathology in the bones, but from renal osteomalacia - thin weak bones prone to spontaneous fracture because of impaired vitamin D and calcium management in sick kidneys.
102
2. The primary target organ of chronic cadmium exposure is the
a. Bone marrow
b. Kidney
c. Liver
d. Lung
e. Bones
2. B - The target organ of chronic exposure is the kidney. Cadmium is bound to a protein called metallothionein in the renal tubule cells; its half life of elimination is about 10 years. Since cadmium exposure is ongoing, cadmium bioaccumulates within the kidney during a lifetime. When the capacity of the tubule cells is exceeded, free cadmium is released and damages the cell. Itai itai (“ouch ouch” ) is an end stage disease in Japanese who ate rice grown in grossly contaminated paddies. The “ouch” is bone pain, that occurs not from primary pathology in the bones, but from renal osteomalacia - thin weak bones prone to spontaneous fracture because of impaired vitamin D and calcium management in sick kidneys.
103
3. Chronic cadmium exposure is best assessed by
a. Analysis of tissue biopsy for cadmium
b. Blood levels of cadmium
c. Cadmium urine levels
d. Cadmium urine levels before and after chelation
e. Urinary albumin excretion
3. C - As for most metals, recent exposure can be assessed by blood levels, but total body burden reflecting chronic exposure is best measured in the urine. Chelation challenge is not useful, and may be harmful if it mobilizes free cadmium into renal cells. Biomonitoring for the earliest signs of cadmium damage to the kidney is done in chronically exposed workers, but the protein investigated are small tubular “microproteins” rather than albumin. Albumin is a large protein that marks of glomerular damage.
104
4. What best describes a metalloid?
a. Element heavier than water that is liquid at room temperature.
b. Elements with properties of both metals and non-metals.
c. Inseparable mixture of 2 or more metals.
d. Chemically altered metal with plastic-like properties.
e. Elements that cannot conduct electricity.
4. B - Metalloids are the elements that have ionization and binding properties that are in-between true metals and non-metals in the periodic table. Metalloids have binding properties of both metals and nonmetals. Metals tend to lose electrons (oxidized). Nonmetals tend to gain electrons (reduced). Metalloids can be either oxidized or reduced in chemical compounds. They can be identified on the periodic table by highlighting in the shape of a stair-step.
105
5. Which of the following is a metalloid?
a. Mercury
b. Cadmium
c. Arsenic
d. Radium
e. Aluminum
5. C - The metalloids are boron, silicon, germanium, arsenic, antimony, tellerium, and polonium. Toxicologically the most significant metalloid is arsenic.
106
6. Metalloids are particularly found in:
a. The semi-conductor industry
b. Space program vehicles
c. Magnetic/antimagnetic ceramics
d. Thermometers and thermistors
e. Antibacterial soaps
6. A - True metals are good conductors of heat and electricity. Metalloids can conduct heat and electricity only under certain circumstances. Thus they are called “semi-conductors” and they are very useful in computer electronics.
107
```
1. Caffeine is pharmacologically and toxicologically similar to what medication?
a. Cyclobenzaprine
b. Theophylline
c. Amitriptylline
d. Carbamazepine
e. Phencyclidine
```
1. B - Caffeine is pharmacologically and toxicologically similar to theophylline.
108
```
2. Which of the following symptoms would not be associated with a caffeine overdose?
a. Tachycardia
b. Vomiting
c. Seizures
d. Restlessness
e. Lethargy
```
2. E - Insomnia, anxiety, restlessness and tremor are common following mild to moderate overdoses. Tinnitus, delirium, headache, low-grade fever, photophobia, and seizures are reported with severe intoxication.
109
```
3. What two fluid-electrolyte imbalances occur following a caffeine overdose?
a. Hypokalemia and hypernatremia
b. Hyperkalemia and hypernatremia
c. Hypokalemia and hyponatremia
d. Hyperkalemia and hyponatremia
e. None of the above
```
3. C – Hypokalemia and hyponatremia can be caused by caffeine toxicity
110
```
4. Which of the following products does not contain caffeine?
a. Coffee
b. Chocolate milk
c. Eggs
d. Iced tea
e. Jolt cola
```
4. C - Eggs do not contain any type of caffeine, unless it would be added to them in the process of cooking or baking.
111
5. Which of the following statements regarding caffeine is true?
a. Caffeine may inhibit theophylline metabolism resulting in an increase in the renal clearance of theophylline.
b. Caffeine constricts the smooth muscle of the bronchi.
c. Caffeine acts on the stomach to decrease gastric acid and pepsin secretion.
d. At the cortical level, caffeine temporarily allays the sensations of drowsiness and fatigue, enhances flow of thought, and permits a greater intellectual effort.
e. Caffeine may induce vasoconstriction of the coronary arteries and vasodilation of the cerebral arteries together with a slight net peripheral vasoconstriction.
5. D - Caffeine exerts its stimulatory effect directly on the cerebral cortex, medulla oblongata, and spinal cord. At the cortical level, caffeine temporarily allays the sensations of drowsiness and fatigue, enhances flow of thought, and permits a greater intellectual effort. At the medullary level, caffeine acts chiefly as a respiratory stimulant.
112
```
1. A patient arrives in the emergency department after ingestion of 50 diltiazem (Cardizem CD®) 300 mg tablets. The patient is alert with a heart rate of 45 beats per minute and a blood pressure of 90/p mmHg. A decision to administer calcium is made. Which calcium salt is the preferred drug for intravenous route?
a. Calcium chloride
b. Calcium gluconate
c. Calcium carbonate
d. Calcium phosphate
e. None of the above
```
1. A - Calcium chloride is thought to produce more predictable increases in extracellular ionized calcium and a greater positive inotropic response. It provides three times more elemental calcium (272 milligrams; 13.6 milliequivalents) than calcium gluconate (90 milligrams; 4.5 milliequivalents) in their commercially available 1 gram ampules.
113
2. Which treatment is not considered useful in the treatment of calcium channel antagonist poisoning?
a. Calcium
b. Glucagon
c. Atropine
d. Hemodialysis
e. Installation of an intraaortic balloon pump
2. D - In general, the large volumes of distribution and high protein binding of all calcium channel blocking agents would suggest hemodialysis or hemoperfusion would have limited usefulness in removal of significant quantities of these drugs.
114
```
3. Which calcium channel antagonist would be expected to result in the most negative inotropic effects after overdose?
a. Nimodipine
b. Verapamil
c. Diltiazem
d. Nifedipine
e. Amlodipine
```
3. B - Hypotension with systolic blood pressures less than 100 mmHg is common following significant overdose with all agents, but particularly with VERAPAMIL; syncopal episodes secondary to impaired perfusion may occur.
115
4. A 2 year old child is found playing with a bottle of his grandfather’s verapamil (Calan SR®) 240 mg tablets. After a pill count, all but one is accounted for. An appropriate disposition would include?
a. Watch the child at home
b. Watch the child at home and administer syrup of ipecac
c. Watch the child in emergency care for 2 hours
d. Watch the child in emergency care for a minimum 8 hours
e. Watch the child in intensive care for 48 hours
4. D - All patients with a history of calcium antagonist ingestion should have a baseline electrocardiogram and be monitored for a minimum of 8 hours. Consider longer monitoring/observation for patients with a history of ingesting sustained-release products.
116
```
5. The following constellation of vital sign abnormalities would be consistent with calcium channel blocker poisoning except?
a. Decreased heart rate
b. Decreased blood pressure
c. Normal temperature
d. Increased heart rate
e. Normal respiratory rate
```
5. E - Noncardiogenic pulmonary edema has been reported following DILTIAZEM and VERAPAMIL overdose, which could cause respiratory symptoms. Kussmaul respiration was described 2 hours after ingestion of 2.4 grams of VERAPAMIL.
117
```
1. Which mothball would you not expect to be radiopaque?
a. Camphor
b. Naphthalene
c. Paradichlorobenzene
d. Oxybenzamine
e. All are radiopaque
```
1. A - Camphor is a translucent crystalline mass, blocks, or powdery masses, with characteristic penetrating aromatic odor and pungent aromatic taste. It is not radiopaque.
118
```
2. Three, 3 year old males are found playing with an empty box of mothballs containing naphthalene. Assuming they all were exposed to equal quantities, which characteristics of the child may place them at greater risk for toxicity?
a. They are at equal risk
b. Asthma history
c. Depressed G6PD activity
d. Previous exposure history
e. Their lean body weight
```
2. C - Infants and patients with G-6-PD deficiency, sickle cell anemia, or sickle trait are more likely to develop hemolysis and methemoglobinemia.
119
```
3. A 20 year old female ingests 3 paradichlorobenzene mothballs in a suicide attempt. Toxicity expected would include:
a. Seizures and respiratory depression
b. Minimal toxicity expected
c. Hepatic failure
d. Renal failure
e. Pulmonary failure
```
3. B - Individuals who are exposed to higher concentrations of paradichlorobenzene may show weakness, dizziness, and weight loss. Vomiting may occur. Greater than 3 mothballs should be considered higher concentrations.
Refer:
Camphor or Unknown >1 mothball
Naphthalene or Para-dichlorobenzene > 5
120
```
4. A child is found seizing in the attic of an old house. A "mothball" odor is detected. Identify the mothball and associated "antidote" for the seizure.
a. Paradichlorobenzene: benzodiazepines
b. Camphor: benzodiazepines
c. Naphthalene: pyridoxine
d. Paradichlorobenzene: pyridoxine
e. Camphor: pyridoxine
```
4. B - Camphor causes seizures and the first line of treatment would be benzodiazepines.
121
5. Monitoring after naphthalene exposures should include the following:
a. Urine dipstick for hemoglobin, peripheral blood smear
b. Ammonia levels
c. SMA-7, LFT's
d. PT monitoring and LFT's
e. Serum osmolarity
5. A - Naphthalene can cause hemolysis and therefore patients should be monitored for hemoglobin in the urine after significant ingestions.
122
```
1. Which organ is NOT considered a target for carbon monoxide poisoning?
a. The brain
b. The liver
c. The blood
d. The heart
e. They all are directly targeted
```
1. B - Primary manifestations of carbon monoxide toxicity develop in the organ systems most dependent on oxygen utilization: the central nervous system and the myocardium.
123
2. Which toxin generates carbon monoxide endogenously?
a. Carbon monoxide released from car exhaust
b. Methane
c. Propane
d. Methylene chloride
e. Butane
2. D - Methylene chloride is metabolized in part to carbon monoxide and may cause elevations in carboxyhemoglobin (COHb), rarely as high as 50% in severe exposures
124
```
3. Which of the following is NOT considered a source of exposure to carbon monoxide?
a. Paint stripper
b. Ice rink Zamboni machines
c. Car exhaust
d. A gas leak
e. Charcoal briquettes
```
3. D - A simple gas leak, without incomplete combustion would not cause carbon monoxide poisoning. Would be a simple asphyxiant.
125
```
4. A 20 year old male is found unconscious after exposure to carbon monoxide through car exhaust. The first management employed should include:
a. Hyperbaric oxygen
b. 100% oxygen
c. Removal from exposure
d. Glucose
e. 70%/30% mixture of oxygen
```
4. C - Need to move person to fresh air prior to attempting any other means of revival. Removing the source would decrease chances of potential toxicity.
126
```
1. Which of the following toxins are corrosive?
a. Hydrogen peroxide
b. Acids
c. Bases
d. Phenol
e. All of the above
```
1. E - Some substances may be irritating or corrosive depending on the concentration, molarity, and other factors. In general, serious esophageal injury is associated with ingestion of products with a pH of 11.5 or higher. Examples of these are hydrogen peroxide, acids, alkalis, and phenols.
127
```
2. The mechanism of burn seen after alkaline exposure is:
a. Coagulation necrosis
b. Liquefaction necrosis
c. Irritant
d. Lipid depleting
e. Fatty deposition
```
2. B - Alkaline corrosives cause liquefaction necrosis, allowing deep penetration into mucosal tissue as cells are destroyed.
128
```
3. A 56 year old biomedical engineer gets splashed in the dorsal aspect of his arm with 95% phenol solution. Which of the following choices would be considered appropriate management?
a. Apply vitamin E
b. Do nothing; it is not corrosive
c. Rinse with PEG solution
d. Rinse with acetic acid
e. Rinse with milk
```
3. C - Decontamination of a dermal exposure may be accomplished with polyethylene glycol 300 or 400, isopropyl alcohol, or copious amounts of water. Decontamination personnel should take precautions.
129
```
4. In which occupation would you see use of silver nitrate?
a. Tire industry
b. Shoe makers
c. Airplane builders
d. Photographic filmmaking
e. None of the above
```
4. D - Silver nitrate is used in the manufacture of silver chloride, photographic sensitive materials, photographic plating, mirrors, catalysts, and pharmaceuticals. It may also be used in photographic dark rooms
130
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5. A 45 year old male is splashed with 100% hydrofluoric acid while at work. A specific antidote useful in this situation is:
a. Calcium for hypocalcemia
b. Calcium for hyperphosphatemia
c. Phosphates for hypercalcemia
d. Phosphates for hypophosphatemia
e. None, there is no special therapy
```
5. A - Calcium gluconate or calcium carbonate gel applied topically to the affected area has been associated with relief of pain at the site of exposure. Systemic toxicity or severe tissue damage is unlikely to occur with small surface area exposures to dilute solutions. Correct known or suspected hypocalcemia with calcium.
131
```
1. A 21 year old male is brought into the emergency department after illicit drug use. He is agitated with vital signs including a heart rate of 130 beats per minute and a blood pressure of 140/90 mmHg. His temperature is 104 F and his respiratory rate is 26 breaths per minute. His pupils are dilated and he is diaphoretic. The most likely toxin to be associated with his findings is:
a. Cocaine
b. Phencyclidine
c. LSD
d. Psilocybin
e. Marijuana
```
1. A - The signs and symptoms of cocaine intoxication are related primarily to its sympathomimetic and local anesthetic effects. Symptoms commonly noted include agitation, tachycardia, hypertension, mydriasis and diaphoresis. Chest pain with or without evidence of myocardial infarction may be noted.
132
2. A plane from South America arrives with one of its passengers complaining of severe abdominal pain. Upon further inspection, the passenger is found to have several wrapped substances in his gastrointestinal tract (visualized by abdominal radiograph). This patient is transferred to a local HCF. What recommendations for treatment would be the best?
a. A dose of charcoal and then begin whole bowel irrigation
b. Lavage and charcoal
c. Surgical removal of the packets
d. Ipecac
e. None of the above
2. A - Whole Bowel Irrigation (WBI) may be a relatively safe and effective means of rapid decontamination for the asymptomatic body packer. Activated charcoal should be administered prior to beginning whole bowel irrigation as polyethylene glycol (PEG) solution decreased the ability of charcoal to adsorb charcoal in vitro.
133
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3. All of the following life-threatening signs and symptoms have been attributed to cocaine except:
a. Bowel infarction
b. Hypothermia
c. Hypertensive crisis
d. Cardiac arrest
e. Ventricular tachycardia
```
3. B - HYPERTHERMIA is common and life-threatening and may be due to increased muscular activity, vasoconstriction, and perhaps a direct effect on the hypothalamus. Sinus tachycardia, atrial arrhythmias, PVCs, bigeminy, and ventricular fibrillation have been reported.
134
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4. All of the following would be considered a treatment for cocaine poisoning except:
a. Diazepam
b. Ice cooling
c. Intravenous fluids
d. Phenobarbital
e. Propanolol
```
4. E - Propranolol is NOT a SPECIFIC antidote for cocaine overdose. Propranolol has been associated with increased blood pressure in the setting of cocaine overdose, presumably due to unopposed alpha adrenergic stimulation.
135
```
5. Which of the following routes can be used for cocaine abuse?
a. Intranasal
b. Oral
c. Intravaginal
d. Intravenous
e. All of the above
```
5. E - ALL ROUTES OF ADMINISTRATION (intranasal, oral, rectal, intravenous, inhaled, and intravaginal) have been associated with the effects described below. There may be no difference in cocaine's clinical toxicity whether smoked or injected intravenously.
136
1. The mechanism of action of cyanide is
a. Simple asphyxiation
b. Impaired oxygen uptake
c. Impaired oxygen delivery
d. Impaired aerobic energy production
e. inhibition of neurotransmitter release
1. D - Cyanide is considered a chemical asphyxiant. Oxygen uptake through the lungs, transport on hemoglobin and delivery to tissues are normal. However, cyanide binds to and renders impotent the iron-containing cytochome protein in the metabolizing tissues such that it cannot hold oxygen and use it in aerobic energy production. Symptoms occur first in the CNS and cardiovascular systems, which are the most sensitive to loss of cellular energy.
137
2. The management of cyanide poisoning includes all of the following EXCEPT:
a. Oxygen
b. Sodium nitrite
c. Sodium thiosulfate
d. Bedrest
e. Methylene blue
2. E - Methylene Blue
Supplemental oxygen remains the most important therapy, and is always included in treatment regimens. In severe cases unresponsive to usual antidotal measures, hyperbaric oxygen has been suggested. Nitrite, either inhaled as amyl nitrite ampules and/or intravenous injection as sodium nitrite is given. In theory, the methemoglobin produced by nitrite is better able to attract cyanide off the tissue cytochromes which restores their function. Sodium thiosulfate is then given to act as a substrate for the enzyme rhodenese, which accelerates the metabolism of cyanide to the less toxic thiocyanide which is then excreted. The patient should always be kept calm, warm, and at rest, preferably lying down, to minimize oxygen demand. Furthermore, antidotal nitrite may precipitously drop blood pressure, so the patient should be recumbent.
*Methylene blue would be contraindicated since the reversal of methemoglobin would release the cyanide back to bind upon the cytochromes.
138
3. Sources of cyanide exposure include all of the following EXCEPT:
a. Building fires involving plastics
b. Charred meat
c. Metabolism of organic nitriles such as acetonitrile
d. Bitter almonds and seeds within fruit pitts
e. Cigarette smoke
3. B - Any material containing nitrogen can produce hydrogen cyanide under fire conditions including common household synthetics such as plastics. Organic nitriles are metabolized to cyanide; symptoms compatible with cyanide toxicity may evolve several hours after exposure. Bitter almond (not to be confused with the sweet almond which is edible) and the seeds of pitted fruits of the Prunus species such as apricots and cherries, contain cyanogenic glycosides, which are also metabolized in vivo to free cyanide. Cigarette smoking is the single largest source of cyanide exposure outside of cyanide-using industries. Charring meat produces Poly Aromatic Hydrocarbons (PAH) and nitrosamines which are potentially carcinogenic.
139
4. The mechanism of action of hydrogen sulfide is
a. Simple asphyxiation
b. Impaired oxygen uptake
c. Impaired oxygen delivery
d. Cytotoxic lung injury
e. Similar to cyanide
4. E - Similar to cyanide
Hydrogen sulfide is a highly toxic gas that is able to react with many proteins containing disulfide bonds. The critical effect is interference with cytochrome oxidase in the tissues, resulting in inhibition of cellular utilization of oxygen and impaired energy production. H2S is a more potent cytochrome oxidase inhibitor than cyanide.
140
5. Risk of hydrogen sulfide exposure is present in:
a. Anaerobic decay of organic matter
b. Use of natural gas
c. Limestone and granite fields
d. Wells dug in coal and oil rich areas
e. Dissolving sulfuric acid in hydrocarbon solvent
5. D – Wells dug in coal and oil rich areas.
H2S may be found in environments where the decay of sulfur - containing organic material occurs by anaerobic or sulfur - producing bacteria. Adequate aeration of sewage, manure pits and other risky collections of organic material prevents production of H2S. Reported risk situations also include sewers and sewage treatment plants, mines, sulfur springs, manure stockpiles, the holds of fishing ships, and wetland construction sites.
H2S is the primary chemical hazard of natural gas production as natural gas, before it is cleaned, may contain several percent hydrogen sulfide (“sour”gas). Natural gas delivered for use as a fuel is not a source of H2S and in fact, another sulfur compound is added as a stenchant to make people aware of an escape of the otherwise odorless gas.
Areas with deposits of organic fuels (peat, coal, gas, oil) are usually found in rocky substrates of sandstone or shale. Subsoil penetration in such areas, as by wells, always carries a risk of H2S exposure.
141
6. The leading toxic cause of sudden death in the workplace is:
a. Cyanide
b. Carbon monoxide
c. Hydrogen sulfide
d. Nitrogen
e. Chlorine
6. C – Hydrogen sulfide.
According to NIOSH, sudden death from acute overexposure to a toxin in the workplace is most often due to hydrogen sulfide. In the petroleum industry alone, more than 1400 significant exposures with nine fatalities occur annually.
142
7. Treatment of hydrogen sulfide poisoning does NOT include:
a. Oxygen
b. Amyl and/or sodium nitrite
c. Sodium thiosulfate
d. Induced methemoglobin formation
7. C - Sodium thiosulfate.
Oxygen is the most important treatment measure after removal from exposure. Administration of a nitrite, either inhaled as amyl nitrite or intravenously as sodium nitrite, appears to release hydrogen sulfide from tissue cytochrome and restore aerobic cellular energy production. Whether the methemoglobin induced by nitrite is partially responsible for the therapeutic effect is controversial. Because thiosulfate is administered as a substrate for an enzyme metabolizing cyanide, it does not have any use in a poisoning by hydrogen sulfide. Keeping the patient, warm, calm, and at rest to minimize oxygen demand is proper management of impaired energy production states no matter their etiology.
143
Cyclic Antidepressants:
1. Sodium channel function in cardiac muscle is best observed in which part of the EKG?
a. The P wave (atrial conduction)
b. The PR interval (atrial-ventricular conduction)
c. The QRS wave (ventricular depolariztion)
d. The Q wave (ventricular repolarization)
e. All of the waves
1. C - The QRS wave (ventricular depolariztion).
The sodium channels embedded in neural membranes are closed and prevent sodium from entering the interior of the cell in the resting state. When a change in membrane voltage occurs, the sodium channels suddenly open, allowing an influx of sodium inside the cell. This rapid shift in sodium ions depolarizes the cell membrane and the action potential is propagated down the nerve. Sodium channels then close again. The Sodium-Potassium ATPase punp uses cellular energy to restore the membrane potential back to normal by pumping the sodium back outside the cell to wait for another voltage signal to the sodium channels.
The EKG records the initiation and spread of the depolarization wave and subsequent repolarization throughout the heart. The P wave represents depolarization of the atria; the PR interval records the delay in transmission of the action potential from the atria through the AV node. The QRS wave records the spread of depolarization through the ventricles, and the Q wave records repolarization of the ventricles. The QT interval measures the ventricular phase of the cardiac cycle- both depolarization and repolarization.
Because of the mass of the ventricles compared to the other cardiac tissue, and their specialized super-fast conduction system (Bundle of His, and its right and left bundles) the best part of the EKG to show the function of the sodium channel is the QRS wave.
144
2. Which anticonvulsant should be avoided in treatment of seizures in cyclic antidepressant poisoning?
a. Pentobarbital
b. Fosphenytoin
c. Diazepam
d. Lorazepam
e. Fentanyl
2. B - Since phenytoin, and its parenteral form phosphenytoin, have an anti-seizure effect by interfering with action of the sodium channel, it is probably best to avoid this in poisonings already complicated by blockade of the sodium channels such as occurs in cyclic antidepressant poisoning.
145
3. A depressed patient ingested all of his medication. Although he was awake and alert on arrival to the emergency room, he suddenly lapsed into coma, and had a brief grand mal seizure. The most likely agent of intoxication is:
a. Valproic acid
b. Bupropion
c. Sertraline
d. Amitryptyline
e. Alprazolam
3. D - Amitryptyline.
Sudden onset of CNS depression with rapid progression into coma is a classic presentation of cyclic antidepressant poisoning. Both seizures and arrhythmia are possible features. If sodium channel block is significant, the QRS wave on the EKG will widen. Wide QRS is a marker for increased risk of seizure as well as arrhythmia. However, therapy with sodium bicarbonate will reduce only the risk of arrhythmia; it does not reduce the risk of seizure or lighten the coma.
146
1. Sibutramine (Meridia) is a drug used in the treatment of obesity. Sibutramine is a(n):
a. Amphetamine and antidepressant
b. Anticholinergic drug
c. Bulk-forming laxative
d. Local anesthestic
e. Nonamphetamine drug and antidepressant
1. E – Sibutramine is a nonamphetamine appetite suppressant that is also known to block the reuptake of norepinephrine, serotonin and some dopamine at the neuron.
147
2. A 22 year old woman with a history of obesity and depression is brought to the emergency department by her boyfriend approximately five hours after ingesting 30 tablets of diethylpropion hydrochloride 75mg (Tenuate Dospan®) in an attempt to harm herself. In the emergency department she is crying, agitated, moving continuously and verbalizing a desire to die.
Vitals: 182/105, 131, 28, 38.2
Labs: Na 141, K 3, Cl 106, CO2 17, BUN 12, Cr. 0.6, Glu 120, CK 1243. Urine + hemoglobin.
```
Which of the following intervention may be useful in managing this patient?
a. Intravenous benzodiazepine
b. Hemodialysis
c. Ipecac syrup administration
d. Restrict intravenous fluids
e. Urinary acidification
```
2. A – Intravenous benzodiazepine.
Diethylpropion hydrochloride is a drug that has pharmacological properties similar to amphetamines. This patient is exhibiting signs of toxicity (fever, tachycardia, hypertension, fever, rhabdomyolysis, agitation, acidosis and hypokalemia). Intravenous benzodiazepines would be useful in decrease movement and thereby decreasing heart rate, blood pressure, fever, and muscle breakdown.
148
```
3. Overdose of orlistat (Xenical) may cause:
a. Coma
b. Decrease in platelet count
c. Diarrhea
d. Prolongation of the QRS interval
e. Seizures
```
3. C - Diarrhea
Orlist is poorly absorbed across the gastrointestinal (GI) tract whereas, GI effects may occur, systemic toxicity is not expected.
149
```
4. An 18-year-old woman ingested about 90 tabs of an over-the-counter diet aid containing ma huang in suicide attempt about four hours ago. A toxic effect that may occur with this ingestion includes:
a. Hypoglycemia
b. Hypokalemia
c. Hypothermia
d. Sedation
e. Vasodilation
```
4. B – Hypokalemia
Ma huang is a source of ephedra. Toxic effects of oral sympathomimetics may include hyperglycemia, hyperthermia, hypokalemia, agitation, and vasoconstriction.
150
5. A 13-year-old girl is brought to the emergency department by her family for “flu” symptoms. Physical examination reveals a malnourished female with vomiting and diarrhea. Hypotonia, dehydration and absence of subcutaneous fat are noted. Patient weight is 30.9kg (68 pounds). EKG findings include prolongation of the QTC interval, sinus tachycardia with premature ventricular contractions.
Vitals: 92/50, 12, 16, 36.0.
Labs: Na 138, K 3.0, Cl 90, CO2 20, BUN 29, Cr. 1.3.
```
Which of the following most likely explains this patient’s clinical presentation?
a. Chromium picolinate use
b. Guarana abuse
c. Ipecac syrup abuse
d. Ma huang use
e. Orlistat use
```
5. C - Ipecac syrup abuse.
This patient has evidence of Ipecac syrup abuse (hypotonia, hypochloremia, hypokalemia, tachycardia with QTC prolongation, PVCs, as well as dehydration). Orlistat has limited absorption across the gastrointestinal tract; it would not cause significant systemic toxicity. Guarana, a source of caffeine, and ma huang, a source of ephedra, are unlikely etiologies due to the lack of stimulant effects.
151
6. Which of the following may be useful in managing the patient with chronic use of supra-therapeutic doses of chromium picolinate for weight loss?
a. Consider hemodialysis to remove chromium
b. Monitor liver enzymes and renal function
c. Supplement diet daily with vitamin C 5000mg
d. Collect hair sample for analysis
e. Consider endoscopy for esophageal necrosis
6. B – Monitor liver enzymes and renal function.
Chronic supra-therapeutic doses of chromium picolinate has resulted in elevated liver enzymes and renal impairment. Hemodialysis does not effectively remove chromium picolinate. This dietary supplement may cause mild gastrointestinal distress, however, corrosive effects are not expected.
152
```
1. Cardiac glycosides are found in all of the following plants except:
a. Oleander
b. Foxglove
c. Lily of the valley
d. Water hemlock
e. Red squill
```
1. D - water hemlock is a stimulant
153
```
2. Which of the following is the antidote for digitalis overdose?
a. Physostigmine
b. Methylene blue
c. Digibind
d. Calcium gluconate
e. Naloxone
```
2. C - Digibind –This is digoxin-specific antibiodies that have a high binding affinity for digoxin, digitoxin, and cardiac glycosides. The Fab fragments bind to the digoxin and the molecule is no longer pharmacologically effective.
154
3. What is the proposed mechanism of action of the cardiac glycosides?
a. Increase activity of the sodium/potassium ATPase pump
b. Inhibits the function of the sodium/potassium ATPase pump
c. Increases atrioventricular node conduction
d. Decreases automatically in Purkinje fibers
e. Increases sinoatrial activity by decreasing vagal tone
3. B - Inhibits the function of the sodium/potassium ATPase pump.
Cardiac glycosides inhibit the function of the sodium-potassium-ATPase pump. After acute overdose, this results in hyperkalemia.
155
```
4. The LEAST likely digitalis toxic rhythm disturbance is:
a. Paroxysmal atrial tachycardia
b. Multifocal junctional extrasystoles
c. Premature ventricular extrasystoles
d. Bigeminal atrial bradycardia
e. Atrial fibrillation
```
4. E – Atrial fibrillation.
Although almost any rhythm can be seen with digitalis toxicity it is unlikely to see atrial fibrillation.
156
1. Which of the following is FALSE regarding the disulfiram reaction?
a. Depends on the dose of disulfiram
b. Depends on the dose of ethanol
c. The reaction is independent of the dose of ethanol
d. Reactions do not occur unless the patient has been on disulfiram therapy for one day
e. Blood disulfiram levels are not of value in diagnosis or treatment
1. D - Reactions do not usually occur unless the patient has been on oral disulfiram therapy for at least 1 day; the reaction may develop up to several days after the last dose of disulfiram.
157
```
2. The clinical presentation of an acute disulfiram overdose include all of the following except:
a. Vomiting
b. Lethargy
c. Ataxia
d. Metabolic acidosis
e. Seizures
```
2. D - Metabolic acidosis
The presenting symptoms are typically flushing, tachycardia, diaphoresis, nausea, vomiting, ataxia, lethargy, seizures, palpitations, headache and chest pain.
158
```
3. Which of the following drugs produces a disulfiram-like reaction with alcohol?
a. Prochlorperazine (Compazine)
b. Fluconazole (Diflucan)
c. Metronidazole (Flagyl)
d. Cimetidine (Tagamet)
e. Acetaminophen (Tylenol)
```
3. C- Concurrent use of ETHANOL and METRONIDAZOLE may result in disulfiram-like reaction (flushing, increased respiratory rate, tachycardia) or sudden death. Avoid ethanol ingestion while on metronidazole therapy. In addition, ethanol beverages or products containing ethanol should not be consumed for at least three days after the discontinuation of metronidazole treatment.
159
4. Which of the following is an antidote for the disulfiram-ethanol reaction?
a. Sodium bicarbonate
b. Ethanol
c. Metronidazole
d. Methylene blue
e. There is no antidote; treatment is mainly supportive
4. E - there is no antidote for a disulfiram-ethanol interaction; treatment is mainly supportive and could include IV fluids, metoclopramide, and norepinepherine.
160
```
1. Hemodialysis is NOT indicated for treating toxic ingestions of:
a. Nifedipine
b. Lithium
c. Theophylline
d. Phenobarbital
e. Aspirin
```
1. A – Nifedipine is a calcium antagonist and should be treated with calcium and/or glucagon. Due to the extensive protein binding dialysis is not effective.
161
```
2. Alkalinization of the urine may be used to enhance elimination of:
a. Acetaminophen
b. Phenytoin
c. Lithium
d. Amitriptylline
e. Aspirin
```
2. E - Aspirin
Urine alkalinization is effective in enhancing the urinary excretion of salicylates.
162
```
3. Hemoperfusion is effective for treating toxic exposures to:
a. Amphetamines
b. Imipramine
c. Lead
d. Theophylline
e. Ethylene glycol
```
3. D – Theophylline can have enhanced elimination by hemoperfusion. This should be done if the pt. is in status epilepticus or if the serum concentration is greater than 100mg/L.
163
```
4. Multiple-dose activated charcoal may enhance the elimination of:
a. Ephedrine
b. Ergotamine
c. Theophylline
d. Iron
e. Fluoxetine
```
4. C - Theophylline
| Can be used for stable patients.
164
```
5. Which is the best treatment for a patient with a blood methanol level of 150 mg/dL?
a. Hemofiltration
b. Hemoperfusion
c. Multiple-dose activated charcoal
d. Hemodialysis
e. Peritoneal dialysis
```
5. D - Hemodialysis rapidly removes both methanol and formate.
The indications are suspected methanol poisoning with significant metabolic acidosis, an osmolar gap greater than 10mOsm/L, or a measured serum methanol concentration greater than 40mg/dL.
165
```
1. The ergot derivatives are used primarily to:
a. Treat fungal infections
b. Treat respiratory infections
c. Treat migraine headaches
d. Anesthetize patients prior to surgery
e. Treat diarrhea
```
1. C - Treat migraine headaches. Ergot derivatives are powerful vasoconstrictors and reduce or prevent the cerebral vasodilation associated with migraine headaches.
166
```
2. Which of the following is the most serious toxicity of the ergotamines?
a. Metabolic acidosis
b. Sustained vasoconstriction
c. Hypercalcemia
d. Hypocalcemia
e. Oxalate crystals in the urine
```
2. B - Sustained vasoconstriction. Per Poisindex, “The major pharmacological effects (of ergot alkaloids) include smooth muscle stimulation, resulting in vasoconstriction.”
167
```
3. The clinical presentation of ergotamine toxicity includes which of the following?
a. Blue-green vomitus
b. Loss of peripheral pulses
c. Esophageal ulceration
d. Hypotension
e. Increased bowel sounds
```
3. B - Loss of peripheral pulses. Per Poisindex, “Toxicity from ergot alkaloids generally manifests as focal or generalized arterial spasm with extremity or organ ischemia.”
168
```
4. The treatment of choice for decontamination following an acute ingestion of ergotamines is:
a. Dialysis
b. Hemoperfusion
c. Whole bowel irrigation
d. Activated charcoal and a cathartic
e. An antidote
```
4. D - Activated charcoal and a cathartic.
Per Poisindex, “Ergotamine is absorbed erratically, incompletely, and slowly from the GI tract following therapeutic oral doses”; so that binding the drugs with activated charcoal might be useful. “Antidotes” are not means of decontamination. The use of extracorporeal means of removal like dialysis and hemoperfusion has not been proven effective.
169
```
1. The systemic ethanol concentration may be estimated by:
a. Liver enzymes
b. Renal panel
c. Calculating an osmolar gap
d. Respiratory rate
e. Clinical presentation of symptoms
```
1. C - Calculating an osmolar gap.
Per Poisindex, “Serum or plasma osmolality allows estimation of blood ethanol level. A blood ethanol concentration of 150 mg% (32.5 mmol/L) increases osmolality by 21.6 milliosmoles/kg water. The following equation gives a very good correlation with blood ethanol concentration (Weiss & Thurnheer, 1988).
BAL (g/L) = osmolal gap/27”.
170
```
2. Ethanol is useful in which of the following situations:
a. Methanol overdose
b. Disulfiram reactions
c. Recreational use
d. Hypoglycemia
e. Decreased osmolar gap
```
2. A - Methanol overdose. Ethanol has a higher affinity for alcohol dehydrogenase, effectively competing with the methanol. This reduces the amount of methanol metabolized to toxic byproducts like formic acid and allows for more urinary excretion of the unmetabolized methanol.
171
```
3. Which of the following clinical effects is seen in an acute ethanol exposure?
a. Tachypnea
b. Hypoglycemia
c. Renal failure
d. Delirium tremors
e. Hypocalcemia
```
3. B – Hypoglycemia.
Hypoglycemia may occur in alcohol intoxication especially in children and alcoholics. The onset of hypoglycemia may be delayed up to 6 hours following ingestion.
172
```
1. A characteristic sign of ethylene glycol toxicity is:
a. Alcoholic ketoacidosis
b. Blindness
c. Calcium oxalate crystals in the urine
d. Gastritis
e. Hypothermia
```
1. C - Calcium oxalate crystals in the urine. Ethylene glycol is metabolized by alcohol dehydrogenase to several toxic organic acids including oxalic acid. Pathologic findings include acute tubular necrosis and presence of calcium oxalate crystals in the kidneys.
173
```
2. The most common formulations of automobile coolant antifreeze contain this chemical as the primary ingredient (up to 95%):
a. Ethylene glycol
b. Sodium hypochlorite
c. Sodium hydroxide
d. Phenylenediamine
e. Ammonium chloride
```
2. A - Ethylene glycol. This differs from automobile windshield washer and antifreeze solutions, which contain methanol. There also is an available antifreeze that contains propylene glycol.
174
3. The Wood's lamp examination is useful in ethylene glycol poisoning because:
a. It measures serum ethylene glycol levels
b. It measures the extent of renal failure
c. It estimates anion gap acidosis
d. It can detect sodium fluorescein
e. It measures the extent of osmolol gap
3. D - Sodium fluorescein may be added to many commercial antifreeze products. A Wood's lamp may assist in confirmation of suspected ethylene glycol ingestion prior to definitive confirmation by glycol serum concentrations. This is not absolutely accurate and the diagnosis of possible EG poisoning cannot be made strictly on the absence of fluorescence.
175
```
4. If urine oxalate crystals are seen following an ethylene glycol poisoning, the treatment of choice is:
a. Gastric lavage
b. Charcoal and cathartic
c. IV alcohol and hemodialysis
d. Obtain an ethylene glycol serum level
e. Whole bowel irrigation
```
4. C - IV alcohol and hemodialysis.
The optimal treatment should be to minimize further metabolism of the EG to toxic byproducts (several toxic organic acids including oxalic acid) while trying to enhance the elimination of unmetabolized EG and those organic acids already produced. Gut decontamination is of little benefit at this point and while serial serum EG levels are useful in directing treatment, they are not therapeutic in and of themselves.
176
5. There is a classic three-stage presentation of symptoms following ethylene glycol poisoning. In order of severity from Stage 1 (least severe) to Stage 3 (most severe) they are:
a. Renal failure; cardiopulmonary failure; CNS depression
b. CNS depression; cardiopulmonary failure; renal failure
c. CNS depression; renal failure; cardiopulmonary failure
d. Cardiopulmonary failure; CNS depression; renal failure
e. Cardiopulmonary failure; renal failure; CNS depression
5. B - CNS depression; cardiopulmonary failure; renal failure.
EG intoxication typically will present with a CNS depression typical of an alcohol inebriation, followed by a significant metabolic acidosis due to the production of several toxic acids, including oxalic acid, with resultant multi-organ failure and then ultimately renal failure secondary to the formation of calcium oxalate crystals in the kidneys.
177
1. Which of the following is a FALSE statement regarding bacterial food poisoning?
a. Most cases are relatively mild and self-limited.
b. Severe and even fatal poisoning may occur with salmonellosis.
c. Some bacterial toxins are heat resistant and once in food are not removed by cooking or boiling.
d. Gastroenteritis is the most common finding.
e. Antidotes have been found to be very useful.
1. E – Bacterial food poisoning is most often caused by Staphylococcus and mild in nature. Most cases respond well simply to symptomatic and supportive care.
178
```
2. Which of the following is a possible source of scombroid food poisoning?
a. Halibut
b. Mussels
c. Tuna
d. Lobster
e. Oysters
```
2. C – The tuna and mackerel are the most common fish in the Scombridae family. They are considered a source of scombroid fish poisoning due to their large amounts of free histidine in their muscle.
179
3. Which of the following is TRUE regarding ciguatera food poisoning?
a. The toxin is produced by dinoflagellates, which are then consumed by reef fish
b. Ingestion of smaller fish is a higher risk than larger fish
c. Since ciguatera is a mixture of histamines, we can treat with antihistamines
d. Respiratory paralysis can occur within 30 to 40 minutes post ingestion
e. Seizures are the most common clinical finding
3. A – The ingestion of the reef-dwelling fish who have in turn ingested toxins produced by dinoflagellates is how a person may get ciguatera food poisoning.
180
```
4. Which of the following types of food poisoning may be confused with an allergic reaction because of the histamine-induced urticaria?
a. Ciguatera
b. Scombroid
c. Paralytic shellfish
d. Neurotoxic shellfish
e. Tetrodotoxin
```
4. B – Scombroid.
The fish implicated in scombroid food poisoning have a large amount of histidine in their muscle. The resultant symptoms are those of a histamine-like reaction therefore mimicking an allergic reaction.
181
```
5. Which of the following toxins is produced in the skin of the puffer fish that results in respiratory paralysis?
a. Tetrodotoxin
b. Scombroid
c. Ciguatera
d. Botulinum
e. Salmonellosis
```
5. A – Tetrodotoxin causes muscular weakness resulting in respiratory paralysis.
182
1. Which of the following statements is NOT true for a chlorine gas exposure?
a. Ocular exposure to liquefied, compressed chlorine gas may cause frostbite to the structures of the eye constituting a medical emergency.
b. Pulmonary edema may occur as a result of inhalation exposure to chlorine gas.
c. When chlorine gas comes in contact with moist mucous membranes, it is converted to hydrochloric acid and “active oxygen”, which damages tissues by disrupting cellular proteins.
d. Inhalation exposures to chlorine gas may occur from mixing household bleach with ammonia-containing cleaners.
e. A degree of tolerance may develop to some of the irritant effects of chlorine gas in chronic industrial exposure.
1. D – Household bleach mixed with ammonia-containing cleaners results in chloramine gas.
183
2. Which of the following treatment options is used for a chlorine gas inhalation exposure?
a. Diuretics will routinely relieve the dyspnea associated with chlorine gas inhalation.
b. Administration of 100% humidified supplemental oxygen, perform endotracheal intubation and assist ventilation as required
c. Bronchospasm resulting from inhalation exposure to chlorine gas is best treated with a regimen of steroids
d. Treatment with cough suppressants should be given as soon as possible after the inhalation exposure
e. Antibiotics should be routinely administered after inhalation
2. B – Administration of 100% humidified supplemental oxygen, perform endotracheal intubation and assist ventilation as required
* Diuretics and cough suppressants are not routine therapy, antibiotics are only given is there is evidence of infection and steroids have not been proven universally beneficial.
184
3. Which of the following statements is TRUE concerning ammonia-containing products:
a. Ammonia blood levels are a useful indicator of exogenous ammonia exposure or toxicity.
b. Commercial preparations of ammonia generally fall in the 27-30% range and are caustic, resulting in tissue damage of the eye, skin and esophagus during contact.
c. Ammonia inhalers, which contain aromatic ammonia spirits, have not been responsible for significant tissue damage due to the small volume of ammonia available.
d. Ingestion of a concentrated ammonia solution rarely causes ulcerative esophagus with resultant stricture.
e. Ammonia is a yellow gas or liquid that has a mild, non-irritating odor.
3. B – Commercial preparations of ammonia generally fall in the 27-30% range and are caustic, resulting in tissue damage of the eye, skin and esophagus during contact.
* Ammonia blood levels are not a good indicator of exogenous ammonia exposure. Ammonia inhalants can cause significant tissue damage, ammonia products have a very irritating odor and ingestion of concentrated forms of ammonia can cause significant ulcerative esophagitis and strictures.
185
4. Which of the following statements is TRUE of chloramine gas:
a. Chloramine gas is liberated by mixing household bleach and acid.
b. Chloramine is used as a disinfectant in household cleaning supplies.
c. A pneumonitis may occur after inhalation of chloramine gas.
d. Gastrointestinal symptoms dominate the clinical picture.
e. Chloramine exposures are likely to cause lethality after a 6 - 8 hour period of exposure.
4. C – Chloramine gas is a strong irritant to the pulmonary system and can progress to a pneumonitis. Chlorine gas is liberated when household bleach and acid are mixed.
186
```
1. Which of the following herbs is being promoted for use in depression?
a. Echinacea
b. Witch hazel
c. Ginkgo
d. Valerian
e. St. John’s Wort
```
1. E – St. John’s Wort is said to have a tonic and tranquilizing action and has been used as an antidepressant.
187
```
2. Echinacea is an herb being promoted for its use in which of the following?
a. To fight depression
b. To reduce symptoms colds and flu
c. Improve digestion
d. To suppress the immune system
e. To decrease pruritis
```
2. B – The benefits of Echinacea are brought about by its ability to act as an immunostimulant. Echinacea does not have any direct bactericidal or bacteriostatic properties.
188
```
3. Which of the following is a popular ingredient in herbal tea and is being promoted for its “anti-stress” effects?
a. St. John’s Wort
b. Valerian
c. Ma huang
d. Ginkgo
e. Chromium
```
3. B – Valerian is touted for use as a sedative, hypnotic and even an anticonvulsant.
189
```
4. Which of the following natural products promoted for its use in insomnia is a hormone produced in the pineal gland?
a. Glucosamine
b. Lecithin
c. Adenosine
d. Melatonin
e. Riboflavin
```
4. D – Melatonin is an endogenous hormone produced in the pineal gland and secreted rhythmically, usually at night.
190
```
5. The herb responsible for the stimulatory effects of Ma Huang tea belongs to:
a. Genus Impatiens
b. Genus Ephedra
c. Genus Agathosma
d. Genus Cocculus
e. Genus Lupulus
```
5. B – Ephedra containing products have strong stimulant effects on the central nervous system and heart.
191
1. Diquat can be best described by which one of the following:
a. Sweet tasting, light green in color.
b. Salty tasting, light yellow or red-brown in color.
c. Strong odor of fresh cut hay, sour tasting.
d. Faint citrus odor, light orange in color.
e. Odorless, colorless liquid, sweet taste.
1 B. - Diquat is pale yellow or reddish brown crystalline solid or dark reddish-brown liquid. It is odorless and has a salty taste.
192
```
2. Progressive pulmonary fibrosis often develops after significant exposure to which of the following toxins?
a. Diquat
b. Carbamate Herbicides
c. Picloram
d. Paraquat
e. Glyphosate
```
2. D. - Paraquat.
Survivors of severe paraquat poisoning often develop progressive pulmonary fibrosis within 5-10 days or longer after exposure. Continued survival depends on the extent of lung involvement.
193
3. The surfactant in combination with the glyphosate found in commercial formulations can cause significant effects such as:
a. Circulatory and respiratory failure
b. Metabolic alkalosis
c. Pallor of lips and nail beds
d. Bulbous skin lesions
3. A. - Circulatory and respiratory failure.
The surfactant present in commercial solutions, polyoxyethylene amine, an anionic surfactant, may be responsible for many of the effects. Surfactants alone may cause circulatory failure, respiratory failure, seizures, generalized edema and gastric erosion. The relative contribution of the surfactant and the glyphosate to the toxic syndrome remains controversial.
194
1. Which of the following type of hydrocarbon is most likely to cause aspiration pneumonitis?
a. High viscosity, high surface tension, high volatility
b. High viscosity, high surface tension, low volatility
c. Low viscosity, low surface tension, high volatility
d. Low viscosity, high surface tension, low volatility
e. Low viscosity, low surface tension, low volatility
1. C - Low viscosity, low surface tension, high volatility
* Viscosity is an internal property of a fluid that offers resistance to flow.
The cohesive forces between liquid molecules are responsible for the phenomenon known as surface tension. The molecules at the surface do not have other like molecules on all sides of them and consequently they cohere more strongly to those directly associated with them on the surface. This forms a surface "film" which makes it more difficult to move an object through the surface than to move it when it is completely submersed.
Volatility describes how easily a substance will vaporize (turn into a gas or vapor). A volatile substance can be defined as (1) a substance that evaporates readily at normal temperatures and/or (2) one that has a measurable vapor pressure. The term volatile usually applies to liquids. The combination of low viscosity, low surface tension, and high volatility make the ingestion of a substance with these characteristics more likely to result in an aspiration pneumonitis
195
2. The act of placing a rag saturated or soaked with a hydrocarbon over the nose and mouth to inhale the vapors is termed:
a. Ragging
b. Sniffing
c. Huffing
d. Puffing
e. Bagging
2. C - Huffing
* Inhalants can be breathed in through the nose or the mouth in a variety of ways, such as:
- “Sniffing” or “snorting” fumes from containers; spraying aerosols directly into the nose or mouth;
- “bagging”–sniffing or inhaling fumes from substances sprayed or deposited inside a plastic or paper bag;
- “huffing” from an inhalant-soaked rag placed over the mouth; and inhaling from balloons filled with nitrous oxide.
196
3. Which of the following hydrocarbons would be the LEAST likely to cause aspiration pneumonitis?
a. Naphtha
b. Motor oil
c. Mineral spirits
d. Gasoline
e. Pine oil
3. B - Motor Oil.
Due to the same considerations discussed above, motor oil, due to its viscosity, surface tension, and volatility would be the least likely of these hydrocarbons to result in an aspiration pneumonitis if ingested.
As you progress from the “thicker” products like motor oil to the “thinner” liquid hydrocarbons like gasoline, the risk of aspiration increases.
197
Hypoglycemic Agents:
· Sulfonylureas (SUL-fah-nil-YOO-ree-ahs) stimulate your pancreas to make more insulin.
· Biguanides (by-GWAN-ides) decrease the amount of glucose made by your liver.
· Alpha-glucosidase inhibitors (AL-fa gloo-KOS-ih-dayss in-HIB-it-ers) slow the absorption of the starches you eat.
· Thiazolidinediones (THIGH-ah-ZO-li-deen-DYE-owns) make you more sensitive to insulin.
· Meglitinides (meh-GLIT-in-ides) stimulate your pancreas to make more insulin.
The major oral medications are in these classes:
· Sulfonylureas (glimepiride, glyburide, chlorpropamide, acetohexamide, tolbutamide, tolazamide) stimulate the beta cells in the pancreas to make and release more insulin.
· Biquanides (metformin) reduce the amount of glucose synthesis and release from the liver.
· Thiazolidinediones (pioglitazone, rosiglitazone) enable increased effectiveness of exisitng insulin in metabolizing tissues.
· Alpha-glycosidase inhibitors (acarbose and miglitol) block the enzymes that digest food starches. This action causes a slower and lower rise of blood glucose through the day, but mainly right after meals.
· Meglitinides (repaglinide) helps the pancreas make more insulin right after meals, which lowers the post prandial rise in blood glucose. It has a fast onset and a short duration that allows more flexibility to vary the times and the number of meals.
198
1. The mechanism of action of sulfonylureas such as glyburide as in diabetes control is:
a. Improved peripheral utilization of existing glucose
b. Enhanced insulin secretion from the pancreas
c. Decreased gastrointestinal absorption of glucose
d. Inhibits release of glucose from the liver
e. Movement of glucose into cells without insulin
1. B - Enhanced insulin secretion from the pancreas
199
2. The mechanism of action of biquanides such as metformin in diabetes control is:
a. Improved peripheral utilization of existing glucose
b. Enhanced insulin secretion from the pancreas
c. Decreased gastrointestinal absorption of glucose
d. Inhibits release of glucose from the liver
e. Allows movement of glucose into cells without insulin
2. D - Inhibits release of glucose from the liver
200
3. The mechanism of action of thiazolidindiones such as rosiglitazone in diabetes control is:
a. Improved peripheral utilization of existing glucose
b. Enhanced insulin secretion from the pancreas
c. Decreased gastrointestinal absorption of glucose
d. Inhibits release of glucose from the liver
e. Movement of glucose into cells without insulin
3. A - Improved peripheral utilization of existing glucose
201
```
4. Ingestion of which of the following can cause permanent diabetes mellitus?
a. Vacor (PNU)
b. Streptomycin
c. Radioactive insulin
d. High dose steroids
e. Glucagon
```
4. A - Vacor
Several toxins are capable of damage or destruction of the beta cells of the pancreatic islets including alloxan, streptozocin and the antimicrobial pentamidine. Vacor (PNU: pyridyl nitro phenyl urea: formerly used as a rodenticide) is such a potent and selective toxin to beta cells that it is used to produce experimental diabetes in animals for laboratory research.
202
```
1. ___________ may not cause toxic effects for hours because it is not active until the liver metabolizes it.
a. VX
b. Sarin
c. DEET
d. Malathion
e. Chlorpyrifos
```
1. E – Chlorpyrifos
| * All are organophosphates except DEET, but that causes neurotoxic effects quickly, so that choice is not correct.
203
```
2. Which of the following best describes the manifestations of organophosphates or carbamates?
a. Nicotinic, muscarinic, CNS
b. Nicotinic, CNS, adrenergic
c. Muscarinic, adrenergic, CNS
d. Nicotinic, muscarinic, adrenergic
e. Nicotinic, muscarinic
```
2. A - Nicotinic, muscarinic, CNS
* Symptoms of organophosphate and carbamate exposures include:
- Muscarinic effects (SLUDGE)
- Nicotinic effects ( tachycardia, hypertension, fasciculations, mydriasis, muscle cramps, weakness, respiratory paralysis).
- CNS effects (CNS depression, agitation, confusion, delirium, coma, and seizures)
204
```
3. Which of the following is not a nerve agent?
a. Sarin
b. Soman
c. Tabun
d. IBP
e. VX
```
3. D – IBP
All are organophosphates, however, IBP has not been developed as a nerve gas for chemical warfare.
205
```
4. Which of the following would NOT be used to treat organophosphate poisoning?
a. Pralidoxime
b. Protamine
c. Atropine
d. Benzodiazepines
e. 2-PAM
```
4. B – Protamine. It is an antidote for heparin overdose.
206
```
1. Which of the following are most likely following lindane (used to treat lice and scabies) exposure?
a. Seizures
b. Hypoglycemia
c. Bronchospasm
d. Cholinergic crisis
e. Hypothermia
```
1. A – Ingestion of as little as 5 milliliters of 1 percent lindane has caused respiratory depression and/or seizures in children.
207
```
2. An infant was covered with mosquito repellant 3 days in a row. On the 3rd day, seizures developed. The child did not appear to be cholinergic. The most likely ingredient or product involved is:
a. Chlorpyrifos
b. Diethyltoluamide
c. Pyrethrum
d. Malathion
e. Avon's Skin-So-Soft
```
2. B – Diethyltoluamide (DEET) toxicity is primarily neurological and does not produce cholinergic symptoms.
208
```
3. Which of the following is not a chlorinated hydrocarbon?
a. DDT
b. DEET
c. Lindane
d. Chlordane
e. Endosulphan
```
3. B - DEET is classified as an insect repellant, not a chlorinated hydrocarbon insecticide.
209
```
4. Which of the following would not be appropriate in the management of a chlorinated
hydrocarbon insecticide ingestion?
a. Observation
b. Ipecac
c. Lavage
d. Charcoal
e. Cholestyramine
```
4. B – Ipecac is contraindicated in hydrocarbon exposures.
210
```
5. Which of the following is least likely to be effective in treating seizures caused by chlorinated hydrocarbon insecticides?
a. Diazepam
b. Midazolam
c. Phenobarbital
d. Pentobarbital
e. Phenytoin
```
5. E – Phenytoin
| * Benzodiazepines and/or barbiturates are generally preferred to phenytoin or fosphenytoin.
211
```
1. A patient with an iron overdose requiring chelation should be chelated with:
a. Calcium EDTA
b. Dimercaprol
c. Deferoxamine
d. DMSA
e. NAC
```
1. C - Deferoxamine is the antidote of choice for iron toxicity.
212
```
2. Which is NOT an indication for chelation of iron overdose?
a. Shock
b. Hypotonia
c. Severe acidosis
d. Iron level >500 with symptoms
e. Iron level greater than the TIBC
```
2. E - Iron level greater than the TIBC
* Indications for chelation are a high iron level and/or symptoms, and all the symptoms listed are consistent with iron overdose. TIBC greater than iron level is no longer used as an indicator.
213
3. Which would probably NOT be helpful in diagnosing a chewable vitamin iron overdose?
a. A negative abdominal X-ray
b. Iron level
c. Gastrointestinal symptoms
d. Lethargy
e. Elevated serum glucose and white blood cell count
3. A - A negative abdominal X-ray
* Although iron is considered a radiopaque toxin, chewable iron dissolves quicker and may not be seen on x-ray even at a toxic level.
214
```
4. A 22 pound child presents to the emergency department 1.5 hours after ingesting three 325mg ferrous gluconate tablets. The appropriate management would include:
a. Milk and 4-6 hours observation
b. Ipecac and 4-6 hours observation
c. 24-hour admission for observation
d. Chelation
e. Hemodialysis
```
4. A - This example is a subtoxic ingestion, so the best choice would be milk and 4-6 hours observation at home.
* (total # tabs) (mg per tablet) (% elemental Fe per tablet)/pt. weight in kg
= mg/kg
1. Ferrous gluconate (12%)
3. Ferrous sulfate (20%)
4. Ferrous fumarate (33%)
1. >/= 10 mg/kg - GI effects
2. >/= 40 mg/kg - systemic effects possible
3. >/= 60 mg/kg - potentially fatal
215
Ferrous gluconate - % of elemental iron
12%
216
Ferrous sulfate - % elemental iron
20%
217
Ferrous fumarate - % elemental iron
33%
218
1. Which of the following statements about isoniazid toxicity is TRUE?
a. Anion-gap metabolic acidosis occurs usually in the patients who develop seizures.
b. Thiamine is the treatment of choice for the seizures.
c. Maculopapular rashes are common with toxicity.
d. Bradycardia and hypertension develop in patients with severe toxicity.
e. Seizures can occur with as little as 5mg/kg ingested.
1. A – anion gap metabolic acidosis is seen in INH exposures.
219
2. Which of the following statements is FALSE?
a. Isoniazid-induced seizures are refractory to treatment with anticonvulsants.
b. If the amount of isoniazid ingested is known, pyridoxine should be given on a gram per gram basis.
c. 10-15 grams are usually fatal without aggressive treatment.
d. Peripheral neuropathy, hepatitis, optic neuritis, and encephalopathy may be seen with chronic ingestion of therapeutic doses.
e. Seizures resulting from an Isoniazid (INH) overdose do not occur until several hours post-ingestion.
2. E – Seizures resulting from an Isoniazid (INH) overdose do not occur until several hours post-ingestion.
* Seizure are often seen within 1 hour of the exposures.
220
3. Which mushroom produces signs and symptoms similar to isoniazid toxicity?
a. Orellanine containing mushrooms
b. Coprine containing mushrooms
c. Muscarine containing mushrooms
d. Monomethylhydrazine containing mushrooms
e. Cyclopeptide containing mushrooms
3. D - Clinical features of Gyromitra mushroom intoxication resemble very closely those symptoms seen in acute overdoses of the drug isoniazid, a hydrazine.
221
```
4. Treatment of isoniazid does NOT include which of the following?
a. Activated charcoal
b. Sodium bicarbonate
c. Pyridoxine
d. Phenytoin
e. Hemodialysis
```
4. D - Phenytoin, which works mainly by blocking rate and frequency dependent sodium channels is ineffective in the treatment of isoniazid seizures and is not recommended.
222
```
1. A patient presents to the ED four hours after ingesting an unknown liquid. Symptoms include bloody emesis, CNS depression, and an osmolal gap. An anion gap is not present, a Wood's lamp evaluation is negative and there is no evidence of oxalate crystals are in the urine. Which of the following is most likely to have been ingested?
a. Ethanol
b. Methanol
c. Isopropyl alcohol
d. Ethylene glycol
e. Propylene glycol
```
1. C –Significant gastrointestinal symptoms resulting in bloody emesis is seen with isopropyl alcohol exposures. The presence of GI symptoms eliminates propylene glycol as a choice. Ethanol, methanol and ethylene glycol exposures present with an anion gap. The presence of calcium oxalate crystals in the urine crystals suggests an ethylene glycol exposure.
223
```
2. Isopropyl alcohol is metabolized to:
a. Ethyl alcohol
b. Methyl alcohol
c. Acetone
d. Ethylene glycol
e. Propylene glycol
```
2. C - Approximately 80% of isopropyl alcohol is metabolized to acetone.
224
3. Which of the following statements about isopropyl alcohol is FALSE?
a. Isopropyl alcohol is generally believed to produce greater CNS depression than ethanol at comparable blood levels.
b. Ingestion or inhalation of isopropyl alcohol results in rapid development of CNS depression and coma, which may be prolonged.
c. Ketonemia and ketonuria may be present, generally with metabolic acidosis.
d. Ingestion, dermal absorption, or inhalation may cause hypothermia, tachycardia, bradycardia, and hypotension.
e. Isopropyl alcohol is used as a solvent, antiseptic, and disinfectant.
3. C - Characteristic laboratory findings of isopropyl alcohol ingestion include euglycemia, ketonuria, ketonemia, increased osmolality, and no evidence of metabolic acidosis.
225
```
4. If severe toxicity due to isopropyl alcohol ingestion requires more than supportive care, which of the following is reasonable in a patient with significant symptoms at 10 hours post-ingestion?
a. Forced diuresis
b. Alkalinization
c. Multiple doses of activated charcoal
d. Hemodialysis
e. Hemoperfusion
```
4. D - Isopropyl alcohol, with a small molecular weight, low volume of distribution and low plasma protein binding, is an ideal molecule for hemodialysis.
226
5. A 3 year old child weighing 15kg may have ingested 10 ml of 70% isopropyl alcohol 5 minutes ago. What would be the most appropriate management?
a. Dilution and observation at home
b. Antacids and observation at home
c. Home administration of charcoal and observation
d. Ipecac and observation at home
e. ED referral
5. A – With minimal ingestions dilution and close follow-up at home is usually sufficient.
227
```
1. Workers scraping lead paint off an old bridge are at risk for developing which of the following symptoms.
a. Anorexia and peripheral neuropathies
b. Alopecia and acrodynia
c. Hyperglycemia and bullous lesions
d. Diaphoresis and tachycarida
e. Conjunctivitis and lacrimation
```
1. A - Gastrointestinal symptoms appear with higher levels of lead and include abdominal pain, anorexia, vomiting and constipation. Neuropathy is one of the oldest described toxic effects of lead.
228
2. A child just ingested a small paint chip. The most appropriate management for single acute exposure would be:
a. No intervention required.
b. Explanation of the potentials of lead toxicity to the caregivers.
c. Referral to the pediatrician for a lead level.
d. Ipecac and home observation.
e. ED referral for decontamination.
2. B - Explain that repeated or chronic exposures can result in toxicity but a small, one-time exposure should not result in harm to an otherwise healthy child.
229
3. A one year old child who presents to the pediatrician with anorexia and vomiting off and on for the last few weeks has a lead level of 60 mcg/dl. Despite this, the child is not dehydrated and appears, clinically, to be doing fairly well. The most appropriate management would be removal from the source of exposure, decontamination of the environment and:
a. Observation only
b. Outpatient treatment with DMSA (Succimer®)
c. Hospital admission and administration of Sodium EDTA
d. Hospital admission and administration of Calcium EDTA
e. Hospital admission and administration of BAL
3. B - Chelation therapy is widely recommended for asymptomatic patients with lead levels between 45 and 70 mcg/dl. Children without overt symptoms may be treated with Succimer that has considerable efficacious and safe use.
230
4. Which of the following is probably NOT a source of lead exposure:
a. Chemical used to manufacture felt hats
b. A buckshot wound
c. Pottery glaze
d. Paint chips
e. Certain herbal products
4. A - Mercury was used to process and form hats from felt made of fur.
231
5. A patient with encephalopathy due to lead exposure should be managed by chelation with:
a. Deferoxamine
b. BAL
c. Prussian blue
d. DMSA
e. BAL, then Calcium EDTA
5. E - Patients with encephalopathy need to be treated aggressively with BAL followed by Calcium EDTA.
232
1. Decontamination/enhanced elimination for lithium exposure may include all of the following, EXCEPT:
a. Lavage
b. Activated charcoal
c. Sodium polystyrene sulfonate
d. Whole bowel irrigation
e. Hemodialysis
1. B - Lithium is not adsorbed to activated charcoal.
233
2. Chronic lithium intoxication is likely to occur due to all of the following, except:
a. New onset renal dysfunction
b. Reduction of sodium intake
c. Dehydration
d. Hepatic dysfunction
e. Diuretics
2. D - Lithium excretion is not dependent on hepatic metabolism.
234
3. Serotonin syndrome could occur in a patient taking lithium in combination with:
a. Diazepam
b. Fluoxetine
c. Chloral hydrate
d. Ibuprofen
e. Acetaminophen
3. B - Fluoxetine and lithium could result in serotonin syndrome as lithium can cause a non-specific increase in serotonin activity.
235
4. Which of the following is NOT an indication for dialysis in lithium ingestions?
a. Renal failure
b. An acute level of 2mEq/L at 10 hours post-exposure with minimal symptoms
c. Seizures
d. Congestive heart failure
e. Mental status changes
4. B - Lithium is rapidly absorbed from the gastrointestinal tract within 1-2 hours. Peak levels occur at 2-4 hours and absorption is complete after 8 hours.
236
5. All of the following symptoms are associated with lithium toxicity EXCEPT:
a. Mental status changes
b. Tremors
c. Hyponatremia
d. Hyperreflexia
e. T-wave inversions
5. C - Hypotnatremia
| * Hypernatermia may be noted in patients with lithium induced diabetes insipidus.
237
1. Which of the following is most likely to be helpful in diagnosing LSD intoxication?
a. Lysergic acid diethylamide levels
b. Presence of visual hallucinations
c. Presence of pinpoint pupils
d. Presence of rotary nystagmus
e. All of the above
1. B - Visual hallucinations are associated with LSD exposures.
238
2. The altered perceptions associated with the use of LSD typically last:
a. 30 minutes
b. 1-2 hours
c. 2-4 hours
d. 6-12 hours
e. 24-48 hours
2. D - Altered perceptions from LSD may last 6-12 hours.
239
3. The mainstay of therapy in the patient who is experiencing LSD intoxication is:
a. Minimization of external stimuli; psychological support
b. Aggressive decontamination of the gastrointestinal tract
c. Pretreatment with chlorpromazine
d. EEG to determine the extent of hallucinogenic activity
e. Physical restraint until all hallucinations have ended
3. A - Maintaining a quiet environment with minimal stimulation and lighting is the therapy of choice for a patient with LSD intoxication.
240
4. Chronic abuse of LSD may lead to which of the following?
a. Agyria (absence of gyri on the surface of the brain)
b. Hepatitis
c. Retinopathy
d. Hallucinogenic persisting perception disorder
e. Cerebral edema
4. D - Hallucinogenic persisting perception disorder (HPPD) or “flashbacks” is an infrequent but significant chronic problem of LSD abuse.
241
1. Which statement about marijuana is FALSE?
a. Marijuana is derived from the hemp plant.
b. Tetrahydrocannabinols are the active ingredients in marijuana.
c. Ingestion of marijuana has minimal clinical effects.
d. Marijuana is absorbed by inhalation.
e. Children and pets are more susceptible to toxic reactions.
1. C - Ingestion of marijuana has minimal clinical effects.
| * Marijuana is absorbed orally.
242
2. Which clinical effect is NOT seen with marijuana use?
a. Decreased testosterone levels
b. Bradycardia
c. Euphoria
d. Stimulation of appetite
e. Conjunctival injection
2. B - Bradycardia
* Physiological effects of marijuana are generally dose-related and include increase in heart rate, variable effects on blood pressure response.
243
3. Treatment of marijuana intoxication does NOT include which of the following interventions?
a. Benzodiazepines
b. Activated charcoal
c. Quiet setting
d. Enhanced elimination
e. Reduced lightening
3. D - Enhanced elimination
| * Symptoms are rarely severe enough to warrant aggressive treatment.
244
4. Which statement about marijuana is FALSE?
a. A mixture of flowers, seeds and stems of the plant Cannabis sativa.
b. The most widely used illicit drug in the United States.
c. Prochlorperazine is a less effective antiemetic agent than marijuana.
d. Considered a “gateway” drug leading to use of other more dangerous drugs.
e. Conservative treatment is usually effective.
4. A - A mixture of flowers, seeds and stems of the plant Cannabis sativa.
* Marijuana is a common name for material obtained from the leaves and flowers of the Indian hemp plant, Cannabis sativa.
245
5. Tetrahydrocannabinol is NOT approved for which of the following indications?
a. Weight loss secondary to anorexia in AIDS patients.
b. Glaucoma.
c. Chemotherapy-induced nausea and vomiting in patients refractory to conventional antiemetic therapy.
d. N-acetylcysteine therapy-induced nausea and vomiting in patients refractory to conventional antiemetic therapy.
e. Multiple sclerosis.
5. D - N-acetylcysteine therapy-induced nausea and vomiting in patients refractory to conventional antiemetic therapy.
* Tetrahydrocannabinol is not indicated to treat nausea and vomiting associated with N-acetylcysteine therapy.
246
1. Which of the following marine animals does NOT require treating a sting/envenomation with soaking the affected limb in hot water (110* to 115* F)?
a. Stingray
b. Red snapper
c. Jellyfish
d. Fire coral
e. Starfish
1. C - Hot water soaks are not the treatment of choice for jellyfish.
247
2. Which of the following treatments would NOT be considered after lionfish envenomation?
a. Supportive care for systemic symptoms.
b. Tetanus prophylaxis
c. Local wound care.
d. Soaking affected limb in hot water (110* to 115* F)
e. Antivenin
2. E- Antivenin is indicated for some marine life exposures, but not for lionfish.
248
3. Which of the following statements is FALSE about jellyfish envenomation?
a. Rinse area of sting with salt water to remove nematocysts.
b. Envenomation can cause pain, erythema, and a burning sensation.
c. Antivenin is available for the North American species.
d. Envenomation may elicit an anaphylactoid reaction.
e. Members of the Coelenterata group account for more marine envenomations than other groups.
3. C - No antivenin is needed or available for North American species.
249
4. All of the following are true about puncture-type fish stings EXCEPT:
a. The pain is far out of proportion to similar mechanical wounds and may persist for hours.
b. Wounds produced by stingrays are usually deep, lacerated and jagged.
c. Wounds tend to bleed more freely than similar non-envenomated injuries.
d. Cardiovascular symptoms and signs may occur, but they tend to be transient in nature.
e. Immediate application of 1:10 household ammonia, vinegar or meat tenderizer may help reduce the pain.
4. E – The treatment for puncture sting is hot water soaks.
250
5. One species of coelenterate known to be lethal is:
a. Portuguese Man O’ War
b. Australian Box Jelly
c. False Coral
d. Hydroids
e. Lionfish
5. B – The coelenterate known to be lethal is the box-jelly or sea wasp (Chironex fleckeri).
251
1. A 2 year old child presents to the ED after biting an oral thermometer in half possibly ingesting some mercury. Your recommendation would be?
a. Administer activated charcoal.
b. Clean out mouth and check the oral cavity for injury from the glass.
c. X-Ray
d. Obtain a 24 hour urine collection for evaluation of mercury.
e. Initiate chelation with BAL.
1. B – Elemental mercury does not cause toxicity unless the mercury is heated or vaporizes.
252
2. Which of the following statements about elemental mercury is FALSE?
a. Elemental mercury is well absorbed from the gastrointestinal tract.
b. Elemental mercury vaporizes at room temperature.
c. Elemental mercury is found in thermometers and barometers.
d. Gingivitis, intention tremor, psychiatric changes, sensory-motor neuropathy can be seen with chronic inhalation.
e. Elemental mercury is the least toxic of the forms of mercury.
2. A - Elemental mercury is not well absorbed from the gastrointestinal tract.
253
3. Which of the following statements about inorganic mercury is FALSE?
a. Found in batteries
b. Absorbed by ingestion, dermal and pulmonary routes
c. Corrosive effects seen (i.e. oral lesions, pain)
d. Activated charcoal binds mercuric chloride
e. Renal effects are not seen
3. E – Inorganic mercury is nephrotoxic.
254
4. Which of the following statements is FALSE?
a. Acrodynia is also known as Pink's Disease.
b. BAL is the chelator of choice for mercury toxicity.
c. Acrodynia is thought to be a mercury-like allergy.
d. 24 hour urine levels are less reliable than spot testing.
e. X-Rays can be useful to assess mercury exposure.
4. D - 24 hour urine tests are the definitive test for mercury toxicity.
255
5. All of the following statements about organic mercury compounds are true, EXCEPT?
a. Organic mercury is poorly absorbed by the gastrointestinal tract.
b. The toxic effects vary depending on the structure of the compound.
c. Alkyl mercuric salts can cause renal damage.
d. Unintentional pediatric ingestions of mercurochrome rarely cause toxicity.
e. Organic mercury can be absorbed through the skin to produce systemic effects.
5. A – Organic mercury is ingested through the food chain
256
1. Which of the following is NOT seen with methanol toxicity?
a. Severe acidosis
b. Edema of the optic disk
c. Crystalluria
d. Inebriation
e. Osmolar gap
1. C- Crystalluria is noted in ethylene glycol exposures but not with methanol toxicity.
257
2. Which of the following is NOT seen with methanol toxicity?
a. A delay in toxicity
b. Toxicity due to toxic metabolites
c. An osmolar gap
d. Hypercalcemia
e. Initial signs and symptoms of confusion and ataxia
2. D – Hypercalcemia is not seen in methanol toxicity.
258
3. Which of the following is NOT an appropriate therapeutic intervention for methanol poisoning?
a. Hemodialysis
b. Folic acid
c. Ethanol
d. Sodium bicarbonate
e. Forced diuresis
3. E - Forced diuresis is not indicated for methanol toxicity.
259
4. Which of the following agents will NOT cause an anion gap metabolic acidosis?
a. Salicylates
b. Lithium
c. Ethylene glycol
d. Methanol
e. Isoniazid
4. B – Lithium is not in the MUDPILES differential of causes of metabolic acidosis.
Common agents that cause an increased anion gap metabolic acidosis are methanol, metformin, uremia, diabetic ketoacidosis, paraldehyde, phenformin, iron, isoniazid, ibuprofen, lactate (shock, seizures, sepsis, ischemia, carbon monoxide, HsS, cyanide), ethylene glycol, salicylates, solvents.
260
1. Which of the following agents is NOT capable of producing methemoglobinemia?
a. Benzocaine
b. Aniline dye
c. Dapsone
d. Sodium nitrite
e. Theophylline
1. E – Theophylline is the only agent listed that does not produce methemoglobinemia.
261
2. Which of the following statements regarding methylene blue is FALSE?
a. Delayed hemolysis may be noted in patients deficient in G6PD. Excessive doses may result in methemoglobinemia.
b. Methylene blue should be given to patients with methemoglobin levels greater than 30%.
c. The correct dose of methylene blue is 1-2 mg/kg intravenously.
d. Methylene blue is ineffective in reversing methemoglobinemia in patients with G6PD deficiency.
e. Methylene blue will not color urine, feces, saliva, skin or mucous membranes a bluish color.
2. E – Methylene blue may color the urine, feces, saliva, skin and mucous membranes a bluish color.
262
3. Which of the following symptoms would NOT be seen in a patient with a methemoglobin level of 40%.
a. Cyanosis
b. Headache
c. Coma
d. Dizziness
e. Fatigue
3. C – Coma would be seen with methemoglobin levels between 55% and 70%.
263
4. Which of the following interventions would NOT be indicated with methemoglobinemia?
a. Withdrawal of offending agent
b. Exchange transfusion
c. Pyridoxine
d. Intensive supportive care
e. Oxygen
4. C – Methylene blue (not pyridoxine) would be used to treat methemoglobinemia. Pyridoxine is commonly used to treat seizures associated with isoniazid overdoses.
264
1. Which statement about Monoamine Oxidase Inhibitors (MAOIs) is FALSE?
a. Patients remaining asymptomatic for 6 hours post ingestion may be discharged.
b. Cardiovascular collapse is seen with severe intoxication.
c. Headache is common.
d. The patient may be hypertensive or hypotensive.
e. Serotonin syndrome is seen when MAOIs are ingested with dextromethorphan.
1. A – The onset of symptoms following acute overdose may be delayed up to 24 hours after ingestion, and effects may last for three to four days.
Common MAOIs:
Isocarboxazid (Marplan) Phenelzine (Nardil) Selegiline (Emsam) Tranylcypromine (Parnate)
265
2. Which of the following drugs does NOT interact with Monoamine Oxidase Inhibitors to produce symptoms?
a. Fluoxetine
b. Dextromethorphan
c. Thiazide diuretics
d. Meperidine
e. Phenylpropanolamine
2. C – Thiazide diuretics
* Severe hypertensive crisis may occur following the combined use of MAOIs and indirect acting sympathomimetics such as phenylpropanolamine.
* Serotonin syndrome may develop in patients taking MAOIs with fluoxetine, meperidine, or dextromethorphan.
266
3. Which if the following foods will not cause adverse reactions when taken with Monoamine Oxidase Inhibitors?
a. Potato salad
b. Red wine
c. Aged cheese
d. Beer
e. Pickled herring
3. A – Potato Salad
* Foods containing high concentrations of tyramine can cause severe MAOI reactions. These include aged cheese, Chianti wine, vermouth, miso, pickled herring and concentrated yeast extracts.
267
4. Which one of the following herbal therapies is reported to have Monoamine Oxidase Inhibitor activity?
a. Echinacea
b. Chromium picolinate
c. Tryptophan
d. St. John’s Wort
e. Kava kava
4. D – St. John’s Wort (hypericum perforatum) has serotonin reuptake inhibition and monoamine oxidase inhibition properties. Drug interactions with SSRIs and MAOIs may result in toxicity.
268
5. Which of the following symptoms is NOT seen with serotonin syndrome?
a. Seizures
b. Rigidity
c. Agitation
d. Miosos
e. Hyperthermia
5. D – Miosos is not seen with serotonin syndrome.
MAOIs, SSRIs, meperidine, dextromethorphan
269
1. Which mushroom species would cause hallucinations after ingestion?
a. Coprinus atramentarius
b. Amanita phalloides
c. Psilocybe cubensis
d. Gyromitra esculenta
e. Clitocybe dealbata
1. C – This mushroom is in the group of psilocybin-containing mushrooms, which cause hallucinations.
270
2. Which mushroom toxin is responsible for the disulfiram reaction when ingested with alcohol?
a. Amatoxins
b. Monomethylhydrazine
c. Muscarine
d. Coprine
e. Psilocybin
2. D – Poisoning by the coprine mushroom is very similar to the alcohol-disulfiram (Antabuse) reaction.
271
3. Which of the following symptoms is NOT expected with Amanita phalloides mushroom ingestion?
a. Liver failure
b. Vomiting
c. Diarrhea
d. Abdominal cramping
e. Methemoglobinemia
3. E – Amanita phalloides is a cyclopeptide-containing mushroom, which is very toxic, but does not cause methemoglobinemia.
272
4. Which of the following statements about mushroom poisoning is FALSE?
a. Toxic and non-toxic mushrooms can be indigenous to the same area.
b. Some classes of mushrooms produce hepatic toxicity.
c. Many species of mushrooms can cause vomiting and diarrhea.
d. Folic acid is the antidote for monomethylhydrazine mushroom poisoning.
e. Activated charcoal should be given in case of mushroom poisoning
4. D – Pyridoxine is the antidote for monomethylhydrazine mushroom poisoning not folic acid.
273
1. Which of the following neuroleptics is LEAST likely to cause extrapyramidal effects?
a. Chlorpromazine (Thorazine)
b. Thioridazine (Mellaril)
c. Haloperidol (Haldol)
d. Perphenazine (Trilafon)
e. Trifluoperazine (Stelazine)
1. B - Thioridazine is low in incidence of extrapyramidal effects when compared with perphenazine, trifluoperazine, and chlorpromazine, extrampyramidal effects may occur with therapeutic effects of haloperidol.
274
2. Which of the following neuroleptic drugs is NOT used for its antipsychotic, sedating properties?
a. Thioridazine (Mellaril)
b. Chlorprothixene (Taractan)
c. Carbadopa/levodopa (Sinemet)
d. Haloperidol (Haldol)
e. Amoxapine (Asendin)
2. C - Carbadopa/levodopa is used for Parkinsonism.
275
3. A syndrome characterized by severe extrapyramidal reactions, hypertonicity of skeletal muscles, fluctuating consciousness, hyperthermia, and autonomic dysfunction is:
a. Acute dystonic reaction
b. Parkinsonian-like syndrome
c. Neuroleptic malignant syndrome
d. Akathisia reaction
e. Tardive dyskinesia
3. C - Hyperthermia and altered mental status would be noted with neuroleptic malignant syndrome.
276
4. An obtunded patient arrives in the emergency department after taking an overdose of thioridazine. The EKG shows prolongation of the PR and QRS intervals and mild ST segment depression. Soon after administration of a dose of activated charcoal, the patient develops ventricular tachycardia. What medications would be the treatment of choice for these ventricular arrhythmias?
a. Lidocaine and phenytoin (Dilantin)
b. Quinidine and disopyramide (Norpace)
c. Lidocaine and procainamide (Pronestyl)
d. Isoproterenol (Isuprel) and procainamide (Pronestyl)
e. Phenytoin (Dilantin) and physostigmine (Antilirium)
4. A - Lidocaine and phenytoin (Dilantin)
| * Any of the Class IA and Class III antiarrhythmics should be avoided due to their potential to prolong QRS interval.
277
5. Which two medications are the treatments of choice for symptoms of acute dystonic reactions?
a. Diphenhydramine (Benadryl) or benztropine mesylate (Cogentin)
b. Haloperidol (Haldol) or chlorpromazine (Thorazine)
c. Epinephrine or dopamine
d. Naloxone (Narcan) or glucose
e. Prednisone or diltiazem (Cardizem)
5. A - diphenhydramine (Benadryl) or benztropine mesylate (Cogentin) is the treatment of choice for dystonia.
278
1. The following symptoms are related to nicotine toxicity EXCEPT:
a. Gastrointestinal symptoms
b. Decreased salivation
c. Tachycardia
d. Agitation
e. Seizures
1. B - Increased salivation may occur with nicotine toxicity.
279
2. A Brazilian tobacco picker presents to the emergency department after long periods of picking tobacco leaves in the rain. Clinical signs include: tachycardia, hypertension, vomiting, confusion, and hyperthermia. Treatment should include:
a. Activated charcoal and observation.
b. Remove contaminated clothing and wash skin thoroughly.
c. No specific decontamination, observation only.
d. Activated charcoal, alkalinization, and observation.
e. Lavage, activated charcoal and observation.
2. B - Remove contaminated clothing and wash skin thoroughly.
* Nicotine is absorbed dermally.
280
3. Other than cigarettes, nicotine can be found in the following forms, EXCEPT:
a. Gum
b. Nasal spray
c. Eye drops
d. Patch
e. Chewing tobacco
3. C – Nicotine is not found in eye drops.
281
4. Why is nicotine not readily absorbed in the stomach?
a. The gastric acid neutralizes the nicotinic acid.
b. The gastric acid substantially inhibits absorption.
c. The anticholinergic effects of the metabolism.
d. Alkalinity of nicotine results in more rapidly excretion in urine.
e. Decrease contact time with gastric mucosa due to spontaneous emesis.
4. B - Ingested tobacco is poorly absorbed across the gastric mucosa because the acid pH of the stomach keeps the nicotine ionized therefore it is not readily absorbed.
282
1. The following statements about NSAIDs are correct EXCEPT:
a. Allergy to a NSAID or aspirin is a contraindication for taking another NSAID
b. These medications may delay the onset of labor
c. Alkalinization of the urine is an appropriate intervention for an ibuprofen overdose
d. NSAIDs should not be taken in latter stages of pregnancy
e. Gastrointestinal bleeding may occur as result of overdose or therapeutic use
1. C - Alkalinization is not recommended in the management of ibuprofen overdose.
283
```
2. NSAIDs normally cause mild toxic symptoms (i.e. nausea, vomiting, and drowsiness). An NSAID that has a predominant finding of seizures and muscle twitching is:
a. Ibuprofen (Motrin)
b. Indomethacin (Indocin)
c. Ketorolac (Acular PF solution)
d. Salsalate (Disalcid)
e. Mefenamic acid (Ponstel)
```
2. E - Seizures are a predominant finding in mefenamic acid overdoses.
284
3. A 15 year old 68 kg depressed female presents to a local emergency department with nausea, vomiting, lethargy and abdominal cramps, after reportedly taking ten 800 mg Motrin, 4 hours prior to being seen in the emergency department. The local health care facility contacts their poison center. The recommendations given by the poison information specialist include which of the following:
a. Administer activated charcoal, draw an ibuprofen level and observe the patient for 4-6 hours.
b. Administer activated charcoal and alkalinize the urine.
c. Observe the patient for symptoms and alkalinize the urine.
d. Administer activated charcoal and 4 grams of cholestyramine (Questran)
e. Infuse intravenous fluids and monitor the patient for fluid and electrolyte imbalance and bleeding.
3. E - Since the time of ingestion is now 4 hours, administration of activated charcoal likely would not be of much benefit to the patient due to the rapid absorption of the ibuprofen.
285
```
4. Mom calls the local poison center after her 2 year old (33 pound) child ingests 12 Children’s Chewable Motrin (100 mg per tablet). The child is asymptomatic. The calculated mg/kg of ingested ibuprofen is:
a. 80 mg/kg
b. 94 mg/kg
c. 6.6 mg/kg
d. 36.6 mg/kg
e. 75 mg/kg
```
4. A - 12 tablets x 100mg/tablet = 1200mg/15kg = 80mg/kg.
286
```
1. Which symptom can occur with opioid poisoning:
a. CNS stimulation
b. Tachypnea
c. Hypertension
d. Gastric hypermotility
e. Non-cardiogenic pulmonary edema
```
1. E - Opioids especially heroin, methadone and propoxyphene can produce non-cardiogenic pulmonary edema often after resuscitation and administration of naloxone. Opioids are associated with CNS depression, respiratory depression not tachypnea, hypotension and gastric hypomotility.
287
```
2. An opioid that may cause mydriasis is:
a. Codeine
b. Meperidine
c. Heroin
d. Hydrocodone
e. Morphine
```
2. B - Meperidine and early Lomotil overdoses are associated with dilated pupils. The other opioids produce miosis.
288
```
3. Naloxone is an opioid antagonist. Naloxone will NOT achieve reversal of CNS and respiratory depression with overdose of which of the following drugs?
a. Methadone
b. Cocaine
c. Pentazocine
d. Propoxyphene
e. Buprenorphine
```
3. B - Cocaine is not an opioid but a sympathomimetic. Although naloxone will reverse the effects of opioids some of these agents require much larger doses of naloxone to reverse their effect. These agents include: codeine, diphenoxylate, fentanyl, methadone, pentazocine, propoxyphene and buprenorphine.
289
```
4. Which opioid has been associated with seizures:
a. Propoxyphene
b. Morphine
c. Hydrocodone
d. Oxycodone
e. Diphenoxylate
```
4. A - Propoxyphene because of its toxic metabolite norpropoxyphene. The following opioids have been associated with seizures: propoxyphene, codeine, pentazocine, meperidine, and methadone.
290
```
5. Which opioid has been frequently associated with cardiac dysrhythmias
a. Propoxyphene
b. Codeine
c. Pentazocine
d. Meperidine
e. Methadone
```
5. A - Propoxyphene because of its toxic metabolite norpropoxyphene.
291
1. Which of the following statements about levodopa is true?
a. Hypertension is generally transient and usually followed by hypotension.
b. Dystonias and dyskinesias are not seen with this medication.
c. Malignant hypothermia has been reported following withdrawal of levodopa therapy.
d. Decreased CPK been reported following overdose.
e. Hyperventilation along with other respiratory dyskinesias have occurred following overdoses of levodopa.
1. A - Levodopa overdose can produce transient hypertension followed by postural hypotension and sinus tachycardia. The other statements are false.
b. Dystonias and Dyskinesias (facial tics, grimacing, head bobbing, torticollis and choreoathetosis) have been reported following chronic therapy.
c. Malignant hypothermia has NOT been reported following withdrawal of levodopa therapy.
d. Increased CPK and myoglobinuria has been reported following overdose.
e. Hyperventilation along with other respiratory dyskinesias have not occurred following overdoses of levodopa.
292
```
2. Which of the following symptoms is NOT associated with overdose of levodopa?
a. Vomiting
b. Sinus tachycardia
c. Restlessness
d. Insomnia
e. Thrombocytopenia
```
2. E - Thrombocytopenia has not been associated with overdose of levodopa. Anorexia, nausea, and vomiting, increased CPK and myoglobinuria has been reported following overdose. Agitation, diaphoresis, insomnia, anxiety, confusion, delirium, hallucinations, and psychosis have occurred in therapeutic doses. Dyskinesias have been reported following chronic therapy.
293
```
3. An overdose of selegiline (Deprenyl) may resemble overdose due to which of the following classes of medications?
a. MAO inhibitors
b. Opiates
c. Salicylates
d. Cardiac glycosides
e. Sulfonylureas
```
3. A - Selegiline is indicated for Parkinson disease and is a selective MAO-B inhibitor which does not pose a threat of food interactions like the traditional MAO inhibitors . In overdose however the selectivity of the inhibition of monoamine oxidase is lost and can produce similar effects.
294
```
4. What is a common complication associated with an overdose of pergolide?
a. Hypotension
b. Asystole
c. Metabolic acidosis
d. Shallow breathing
e. Hypoglycemia
```
4. A - Hypotension
* Pergolide is a drug used for Parkinsonism which is a ergoline derivative and selective dopamine agonist with a high affinity for the D2 receptor site, and to a lesser extent for the D1 receptor site. There are few documented cases of overdoses. Spontaneous vomiting, hypotension, sweating, nausea, dizziness, agitation and hallucinations have been reported as symptoms. Seizures and CNS stimulation have occurred in animal toxicity studies, and may occur following overdoses in humans. Toxicity may result in dyskinesias.
295
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5. Which of the following therapies is NOT considered beneficial in the treatment of neuroleptic malignant syndrome associated with levodopa overdose?
a. Dantrolene
b. Bromocriptine
c. Amantadine
d. Benzodiazepines
e. Cooling blankets
```
5. C – Amantadine.
* Amantadine acts as an antiviral agent and antiparkinson agent. It is a weak dopamine agonist, with some antimuscarinic activity, and a N-methyl-D-aspartate receptor antagonist activity. It is not considered useful for the treatment of neuroleptic malignant syndrome associated with levodopa overdose. The other choices may be beneficial.
296
1. The following statement about phencyclidine (PCP) is TRUE:
a. PCP is an antipsychotic agent.
b. Toxicity is characterized by sedation and quiet behavior.
c. If PCP is dusted on food and ingested it is not considered to be absorbable or capable of producing toxicity.
d. PCP is inactive if smoked.
e. PCP can be easily and cheaply synthesized from ingredients readily available.
1. E - PCP can be easily and cheaply synthesized from ingredients readily available.
a. PCP is a non-dissocative anesthetic agent, not an antipsychotic agent.
b. Toxicity is characterized by signs of adrenergic hyperactivity, including hypertension, rigidity, localized dystonic reaction, hyperthermia, tcahycardia diaphoresis, convulsions and coma.
c. If PCP is dusted on food and ingested it is readily absorbed and can lead to toxicity.
d. PCP is readily absorbed by smoking and is active if smoked.
297
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2. The following street names has NOT been used to refer to PCP:
a. Angel dust
b. Rocket fuel
c. Peace weed
d. Killer weed
e. Adam and Eve
```
2. E - Adam and Eve are slang terms that have been referred to methylenedioxymethamphetamine (MDMA). The other names have been associated with PCP.
298
```
3. The following ocular effects can occur with a PCP overdose, EXCEPT:
a. Blank stare
b. Nystagmus
c. Blurred vision
d. Cortical blindness
e. Dysconjugate gaze
```
3. D - cortical blindness. The other ocular effects have been reported with PCP.
299
4. When dealing with PCP intoxication the following management is recommended:
a. Physostimine can help with hallucinations.
b. Multiple dose activated charcoal has been shown effective in influencing the outcome.
c. Urinany acidification is indicated to increase excretion.
d. Hemodialysis is useful in enhancing elimination.
e. Treating myoglobinuria is important.
4. E - Treating myoglobinuria is important. Rhabdomyolysis may develop from this intoxication which can lead to myoglobinuria and acute renal failure. This can be treated with fluids and sodium bicarbonate therapy.
300
```
5. Which of the following OTC medications has been reported to cause a false positive when screening for PCP?
a. Diphenhydramine
b. Acetaminophen
c. Dextromethorphan
d. Cimetidine
e. Pseudoephedrine
```
5. C - Dextromethorphan has a similar structure as PCP which has been shown to cross-react with PCP on urine assay.
301
```
1. A 13 month old (10 kg) child arrives in the Emergency Department, hallucinating, after eating seeds found in an unmarked baggy. Mom does a lot of gardening and at times places the extra seeds in Ziploc baggies, to keep them fresh. A plant that could cause these symptoms would be:
a. Red squill
b. Castor beans
c. Croton
d. Morning glory
e. Philodendron
```
1. D - Morning glory seeds may contain d-lysergic acid (LSD). It is thought that all cultivars of this class (Ipomoea Tricolor) are hallucinogenic.
302
```
2. A 56 year old male arrives at the ED with the following symptoms: hyperthermia, flushing, dry mucous membranes, mydriasis, tachycardia, decreased GI motility, hallucinations, and mental status depression. His wife states they had picked “parsnips” in a wild field and he had eaten them. The patient must have picked which of the following plants, thinking it was “parsnips”:
a. Water hemlock
b. Henbane
c. Foxglove
d. St. Johns Wort
e. Dumb cane
```
2. B - Henbane (Hyoscyamus nigeris) in the family solanaceae. The whole plant contains hyoscyamine, hyoscine and atropine. The root has been mistaken for horseradish.
a. Water Hemlock is found in swamps, damp meadows and along streams from the Rocky Mountains west to the Pacific. All parts toxic, but the toxicity is more highly concentrated in the lower part of the stems and roots. The toxic agent is cicutoxin. Symptoms that may be produced are: diarrhea, convulsions, tremors, extreme stomach pain, dilated pupils, fever, delirium, bloating, respiratory depression, and death. Symptoms appear within 15 minutes to more than one hour, commonly, within 1/2 hour after ingestion. Death may occur from 15 minutes after ingestion to 8 hours. Ingesting the underground parts has poisoned humans, having mistaken them for parsnips and various other edible roots. A mouthful could be fatal.
c. Foxglove is a cardiac glycoside.
d. St John’s Wort: The foliage and flower petals contain hypericin (a napthodianthrone derivative), as well as several biflavinioids. Symptoms that can be produced are: increase of heartbeat and respiration, fever, diarrhea, photosensitivity, development of erythema and pruritus followed by edematous suffusions and eventual necrosis of the skin. The flowering tops of hypericum perforatum have astringent and diuretic properties.
e. Dumb cane is a synonym for diffenbachia that contains raphides. The raphide contains insoluble calcium oxalate that can produce swelling of the oral mucosa. It has large leaves and is usually kept as an indoor plant.
303
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3. Which of the following plants is NOT considered a cardiogenic glycoside?
a. Fox glove
b. Red squill
c. Oleander
d. Lily of the valley
e. Elderberry
```
3. E – Elderberry. Ingestions of large amounts of the Elderberry fruit may cause GI symptoms (nausea, vomiting, abdominal cramps and diarrhea) and neurological symptoms (dizziness, numbness, and stupor). Ingestions of the stems, roots, or bark, may cause severe diarrhea. Although the stems, leaves, and bark may contain cyanogenic glycosides, no documented cases of human cyanide poisoning have been reported.
304
4. The following statement is TRUE about exposures to a toxicodendrol plant:
a. Produces hallucinations.
b. Produces dry mouth.
c. Is readily transmitted from person to person.
d. Can produce contact dermatitis.
e. Is non-toxic.
4. D - Can produce contact dermatitis.
| * This is the active ingredient in Poison Ivy, Poison Sumac and Poison Oak. The other choices are all false.
305
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5. If a patient arrives in the Emergency Department after ingesting Angel’s Trumpet, you would expect him to exhibit which of the following:
a. Bradycardia
b. Hyperactive bowel sounds
c. Miosis
d. Hypothermia
e. Hallucinations
```
5. E - Hallucinations as they are the anticholinergic effect listed here. Additionally, ingestion of the plant can produce tachycardia, hypoactive bowel sounds, mydriasis, and hyperthermia.
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1. A 45 year old male arrives in the Emergency Department 24 hours after intentionally ingesting D-Con Mouse Prufe II with brodifacoum 0.005% as the main ingredient. Which of the following treatments should be recommended if the PT is prolonged?
a. Vitamin B12
b. Pralidoxime
c. Niacinamide
d. Vitamin K1
e. Pyridoxine
```
1. D - Vitamin K1. There is not a specific therapeutic maneuver other than restoration of prothrombin level to normal if toxicity occurs. Phytonadione (Vitamin K1) is a specific antidote. Menadione (Vitamin K3) should not be administered because it requires hepatic conversion to the active form (phytonadione).
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2. The following statement about Red Squill is FALSE:
a. It is a potent rodenticide isolated from the red tides of the coast of New Jersey.
b. It is a cardiac glycoside.
c. Massive doses can cause ventricular arrhythmias.
d. Can cause blurred vision.
e. Can cause gastrointestinal irritation.
2. A - It is not a rodenticide, but a digitalis-like cardiac glycoside plant in which the glycoside is found in the bulb. Manifestations of toxicity can consist of ventricular arrhythmias, blurred vision and gastrointestinal irritation.
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3. A 3 year old child presents to the Emergency Department after ingesting an unknown type of rodenticide. The child is having prolonged recurrent motor seizures, CNS stimulation, opisthotonus (spasm of the muscles causing backward arching of the head, neck, and spine), and medullary paralysis (respiratory centers in the medulla oblongata of the brain that control breathing and other vital functions cease to function). Which of the following rodenticides should be considered?
a. Warfarin/super warfarin
b. Red Squill
c. Strychnine
d. Thallium
e. Arsenic
```
3. C - Strychnine is a potent rodenticide that has been associated with producing prolonged recurrent motor seizures, CNS stimulation, opisthotonus, and medullary paralysis.
a. Warfarin/super warfarin are anticogulant rodenticides that inhibit coagulation factors II, VII, IX and X that can be monitored by following the prothrombin time.
b) Red Squill is also known as sea onion that is a plant with a bulb. The bulb contains a cardiac glycoside compound.
d) Thallium is a cellular toxin. It behaves as a potassium analogue and is distributed intracellularly to all the tissues of the body. At low levels thallium replaces potassium in the sodium-potassium ATPase pump; at high levels it competitively inhibits sodium potassium ATPase. Thallium also has an affinity for sulfhydryl groups. Symptoms are usually delayed 12 to 24 hours in acute poisoning and reach a maximum stage or phase of intoxication by the second and third week after exposure. Transient nausea and vomiting are generally seen first, followed by a peripheral sensory neuropathy with painful paresthesias in 1 to 5 days or more. Paresthesias have occurred as early as 12 to 13 hours after massive ingestion. Motor neuropathy may develop and in severe cases may lead to cranial nerve palsies and respiratory failure and refractory cardiogenic shock. Alopecia (hair loss - falls out in small patches on the scalp) develops two to three weeks after exposure.
Treatment: Prussian Blue: Although preferred in Europe, Prussian blue is not commercially available in the US and is not FDA-approved.
e) Arsenic inactivates sulfhydryl-containing enzymes such as lactic dehydrogenase in heart muscle, thereby producing toxicity. Similar effects occur in the gastrointestinal tract and in neurologic tissues leading to the observed clinical toxicity.
1. Acute toxicity produces: nausea vomiting diarrhea, fluid/electrolyte loss, hypotension, garlic odor, followed by encephalopathy, seizures, dysrhythmias, ARDS, renal failure, hemolysis, rhabdomyolysis. Peripheral neuropathy and myelosuppression may occur after days to weeks.
2. Chronic toxicity produces: hyperkeratosis, hyper/hypopigmentation, neuropathy, skin and lung cancer. Chelation therapy with BAL or Dimercaptosuccinic acid (Succimer) has been useful. Succimer has less side effects than BAL. D-Penicillamine is an older oral chelator that is rarely used.
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4. Which of the following poison and antidote pairs are CORRECT?
a. Brodifacoum - Vitamin K3
b. Vacor (PNU) - Glycerol monoacetate
c. Sodium monofluoroacetate - Niacinamide
d. Thallium - BAL
e. Lead - Succimer
4. E - Lead – Succimer. Lead poisoning can affect almost every organ system. Organ systems primarily affected include the central and peripheral nervous systems, cardiovascular, gastrointestinal, renal, endocrine, and hematologic systems. Lead can also adversely impact reproductive functioning and the developing fetus and child. The signs or symptoms may be varied and non-specific, and the clinician needs to consider the constellation of complaints and findings that may suggest lead poisoning as the diagnosis. Succimer has been used in children with lead levels over 45ug/dL. EDTA and BAL are alternatives that are used in more severe cases of lead poisoning and are given by injection. EDTA can be given IV, but BAL can only be given IM.
A. Vitamin K1 (phytonadione) not K3 (menadione) is used for anticoagulant rodenticides poisoning from brodifacoum.
B. Vacor is a rodenticide that causes irreversible insulin dependent diabetes. Nicotinamide has been used as an antidote to prevent diabetes.
c. Sodium monofluoroacetate is a highly toxic rodenticide that is rapidly absorbed and may cause systemic toxicity after oral, dermal, inhalation or ocular exposure. Clinical effects usually develop within 30 minutes to 2.5 hours of exposure, but may be delayed as long as 20 hours. Effects of acute exposure commonly include nausea, vomiting and diarrhea. Serious poisoning may result in seizures, coma, respiratory depression, hypotension and cardiac dysrhythmias including ventricular tachycardia and fibrillation and asystole. Cardiovascular toxicities and CNS symptoms predominate.
Treatment: would be to not induce emesis. May consider gastric lavage after ingestion of a potentially life-threatening amount of poison if it can be performed soon after ingestion (generally within 1 hour). Activated charcoal can be given although there is no data on the efficacy of GI decontamination procedures. There is no known antidote for sodium monofluoroacetate intoxication. Symptomatic and supportive care should be provided.
d. Thallium see above explanation.
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5. A rodenticide that has not been commercially available since 1979, but produces extensive destruction of pancreatic beta cells and is treated similar to diabetic ketoacidosis is:
a. Sodium monofluoroacetate
b. Red squill
c. Vacor
d. Paraquat
e. Strychnine
```
5. C - Vacor or PNU is a rodenticide that causes irreversible insulin dependent diabetes and autonomic nervous system injury. Although banned in 1979 it may still be used by some licensed exterminators. Nicotinamide has been used to prevent PNU induced diabetes.
d. Paraquat (dipyridylium) is a highly toxic herbicide. Ingestion of even small amounts of paraquat can result in severe toxicity and death within 24 hours. Gastrointestinal lesions, acute respiratory distress syndrome, renal damage, hepatotoxicity, cardiac arrest, and circulatory collapse can occur. Survivors of severe paraquat poisoning often develop progressive pulmonary fibrosis within 5 to 10 days or longer after exposure. Continued survival is dependent on the extent of lung involvement.
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1. Which of the following would be an indication for performing hemodialysis for a salicylate overdose:
a. Elevated anion gap
b. Acute salicylate level of 60 mg/dL
c. Hepatic compromise
d. Hypoglycemia
e. Persistent CNS disturbance
1. E - Persistent CNS disturbance.
* Hemodialysis is indicated in patients demonstrating severe symptoms and/or high blood salicylate levels. Indications for hemodialysis are:
1. Patients with serum salicylate levels greater than 100 mg/dL in acute intoxication. (Some use >80-100 mg/dL especially with severe symptoms and/or electrolyte disturbance.)
2. Patients with serum salicylate levels greater than 50-60 mg/dL in chronic intoxication. (Some authors recommend at levels as low as 40 mg/dL.)
3. Refractory acidosis (pH <7.1).
4. Persistent CNS symptoms or progressive clinical deterioration despite appropriate fluid therapy and attempted urinary alkalinization especially with persistent elevated salicylate levels.
5. Patients who cannot tolerate the increased solute load as a result of alkalinization, (e.g., congestive heart failure, non-cardiogenic pulmonary edema, cerebral edema, renal failure).
6. Hepatic compromise with coagulopathy.
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2. Which of the following statements pertaining to salicylate poisoning is FALSE:
a. In overdosage, peak serum levels may be delayed after 6 hours, if not longer.
b. Mild symptoms of respiratory alkalosis precede a metabolic acidosis in acute overdose.
c. Altered mental status is considered a sign of serious poisoning in acute overdose.
d. Urinary alkalinization can be useful for salicylate intoxication.
e. In chronic intoxications higher blood levels correlate well with symptoms.
2. E - In chronic intoxications, severe poisoning occurs at lower salicylate levels versus acute ingestions.
* Consider dialysis in patients with serum salicylate levels greater than 50-60 mg/dL in chronic intoxication. (Some authors recommend at levels as low as 40 mg/dL.)
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3. A 22 kg child presents to the Emergency Department after ingesting 10 ml of a 98% methyl salicylate solution. What is the potential amount of salicylate in mg/kg ingested? (1 ml of 98% methyl salicylate = 1.4 gm of salicylate)
a. 22 mg/kg
b. 636 mg/kg
c. 445 mg/kg
d. 527 mg/kg
e. 1369 mg/kg
```
3. B – 1.4 gm = 1,400 mg. 10 ml x 1,400 mg = 14,000mg/22kg = 636 mg/kg.
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4. A 35 year old patient arrives in the Emergency Department, asymptomatic, four hours after ingesting an unknown amount of aspirin (ASA). The initial ASA level is 20 mg/dL. A level repeated two hours later is 25 mg/dL. The doctor contacts the Poison center. Which recommendation is most correct?
a. Send the patient home since the repeat level at six hour is close to a therapeutic level.
b. Administer activated charcoal and continue to repeat ASA levels every 2 hours until see two declining levels.
c. Start urinary alkalinization to decrease ASA levels.
d. Observe the patient for symptoms and follow salicylate levels until declining.
e. Hydrate the patient and then discharge.
4. D - Since the 6 hr level rose from the previous level of 20 mg/dL, the patient needs to be observed longer for a potential delayed peak level. The patient salicylate level needs to be followed until the levels are declining to ensure no development of delayed symptoms.
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5. Which of the following statements regarding the Done nomogram is CORRECT?
a. It is most useful in the treatment of chronic salicylate toxicity.
b. It has severely limited applicability in the treatment of salicylate toxicity.
c. A two hour salicylate level is required to use the Done nomogram.
d. It is useful in providing treatment guidelines.
e. It is used when the patient has ingested enteric-coated aspirin.
5. B - The nomogram was developed using a small number of pediatric ingestions. The nomogram is not useful in sustained release or enteric coated formulations, chronic cases or where there is a bezoar. It does not offer any treatment guidelines and many feel it is not useful for adult ingestions.
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1. A 26 year old female was found unresponsive in her home after drinking 8-10 beers and taking 45 alprazolam (Xanax), unknown strength, approximately 2 hours prior to her arrival in the ED. On presentation to the Emergency Department, she is lethargic with the following vital signs: BP 110/70 mmHg, respirations 15 bpm, and temperature of 99.5 F.
Recommendations should be to:
a. Advise activated charcoal.
b. Advise gastric lavage.
c. Advise symptomatic and supportive therapy.
d. Advise naloxone.
e. Advise flumazenil.
```
1. C - Symptomatic and supportive therapy should be advised. It is too late for any gastronintestinal decontamination to be recommended (> 1 hour post ingestion). Naloxone would not be indicated because no opioids are involved. Flumazenil is not recommended because of the unknown history of benzodiazepine use which could precipitate a withdrawal reaction and the fact the patient is not very symptomatic.
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2. Treatment utilizing gastric lavage with a large bore tube should be considered with which of the following medications due to the risk of concretion formation?
a. Alprazolam
b. Chloral hydrate
c. Glutethimide
d. Meprobamate
e. Buspirone
```
2. D - Meprobamate can form tablet concretions in large overdose.
a. Alprazolam is a benzodiazepine,
b. Chloral hydrate gets metabolized to trichloroethanol - an organic compound related to ethanol. In humans, its pharmacological effects are similar to those of its prodrug, chloral hydrate, and chlorobutanol. It has, historically, been used as a sedative hypnotic,
c. Glutethimide has anticholingeric effects,
e. Buspirone can produce GI distress, drowsiness and miosis in overdose.
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3. A patient presents to the ED with sedation, slurred speech, ataxia, poor judgement and mild respiratory depression.
Which medication would NOT cause the above symptoms:
a. Zolpidem
b. Clorazepate
c. Flurazepam
d. Phenobarbital
e. Phencyclidine
3. E – Phencyclidine (PCP). Phencyclidine is a dissociative anesthetic with sympathomimetic and hallucinogenic properties closely related to ketamine. Pharmacologic effects are generally dose related. PCP is thought to stimulate alpha-adrenergic receptors, potentiating the effects of norepinephrine, epinephrine and serotonin. Common findings in overdose are nystagmus, hypertension, acute brain syndrome, violent/agitated/bizarre behavior, tachycardia, and hallucinations/delusions. Miosis and seizures are more common in children. Hyperthermia and diaphoresis are also common.
The other choices are incorrect because they are all associated with producing CNS depression in overdose.
319
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4. Which of the following clinical features is associated with severe barbiturate overdose?
a. Hyperreflexia
b. Tachypnea
c. Tachycardia
d. Acute tubular necrosis
e. Hypotension
```
4. E - Hypotension can occur in severe cases. Lethargy, slurred speech, nystagmus, ataxia, coma bradycardia and respiratory arrest are also seen in severe barbiturate overdose.
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5. Which of the following statements is TRUE concerning the management of a barbiturate overdose?
a. Alkalinization is effective for short and long acting barbiturates.
b. Alkalinization can be considered in some cases of phenobarbital overdose.
c. Multiple dose activated charcoal does not effect the elimination of phenobarbital.
d. Hemodialysis should be recommended for most chronic barbiturate intoxications.
e. Flumazenil is useful in counteracting the central nervous depression produced by a barbiturate.
5. B - Alkalinization can be considered in some cases of phenobarbital overdose. It can increase the elimination of phenobarbital, but not other barbiturates. Its value in acute overdose is unproven, and it may contribute to fluid overload and pulmonary edema. Alkalinizing the urine may enhance the renal excretion of the drug. A maintenance solution of sodium bicarbonate and potassium chloride in an appropriate intravenous fluid should be administered at a rate to produce a urine flow of 3-6 ml/kg/hr. The goal is to achieve a urine pH of >7-8 and a diuresis in order to "ion-trap" the drug and promote its excretion. Usually, this requires at least 1-2 amps (50 mEq/amp) of sodium bicarbonate per liter of fluid and 20-40 mEq potassium chloride per liter of IV fluids administered at a rate appropriate for the patient's age and weight. It should be started immediately after diagnosis is established. The other choices are incorrect
a. alkalinization is not effective for short acting barbiturates.
c. Multiple dose activated charcoal does speed up the elimination of Phenobarbital.
d. Hemodialysis should not be recommended for most chronic barbiturate intoxications unless in very severe cases.
e. Flumazenil is not effective for barbiturates, but is used for reversal of symptoms with benzodiazepines.
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1. Which gas is NOT a simple asphyxiant?
a. Methane
b. Nitrogen
c. Helium
d. Chlorine
e. Natural gas
```
1. D - Chlorine is considered an irritant gas with intermediate water solubility. Chlorine gas vapors are heavy and settle in low areas; odor is not a good indicator of exposure severity. Chlorine gas is severely irritating on contact and can be corrosive to the eyes, skin, nose, throat, and mucous membranes; exposure can result in severe or permanent eye injury. Contact with the escaping compressed liquid can cause frostbite and/or chemical burns to the eyes and skin. Chlorine combines with tissue water to produce HCl, producing injury and reactive oxygen species.
322
2. A 20 year old male was welding at his workplace on a very hot humid day. He was not wearing any protective equipment. That evening, when getting home after work, he complains of fever, chills, myalgia and headache.
Which of the following reasons likely explain his symptoms?
a. He over exerted himself while at work.
b. He is coming down with the flu.
c. He inhaled fumes from a galvanized pipe he was welding.
d. He had previously sensitized himself to the welding fumes and now he has developed symptoms.
e. He is suffering from polymer fume fever.
2. C - Metal fume fever is the most frequently described occupational respiratory illness reported in welders. Clues typically include mild to moderate flu like symptoms such as fever, chills, myalgia and headache that spontaneously resolve in 1-2 days without treatment. A type of tolerance builds up during exposures, but is lost after a few days of non-exposure. Symptoms often reappear after a weekend away from the job, thus the name Monday Fever.
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3. Metal fume fever, characterized as a flu-like syndrome, is most likely related to the welding or melting of certain materials.
Which choice is one of the most frequent causes of Metal Fume Fever?
a. Arsenic
b. Fiberglass
c. Mercury
d. Cadmium
e. Zinc
```
3. E – Zinc.
* Metal fume fever is an illness produced by inhaling metal oxides. Metal oxides are produced by heating various metals including cadmium, zinc, magnesium, copper, antimony, nickel, cobalt, manganese, tin, lead, beryllium, silver, chromium, aluminum, selenium, iron, and arsenic. The most common agents involved are zinc and copper. Metal fume fever most often occurs after welding or torch-cutting galvanized (zinc coated) metal, such as air conditioning ducting.
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4. Which of the following statements about chlorine gas is FALSE?
a. Mucosal irritation is a common symptom of chlorine gas exposure.
b. Significant exposure to chlorine gas may cause pulmonary edema.
c. Chlorine gas has a direct action on the mucosa of the eyes and respiratory tract.
d. The mixing of common household chemicals such as bleach and ammonia can create chlorine gas.
e. The initial chest x-ray of a severely poisoned patient is often unremarkable.
4. E - The mixing of common household chemicals such as bleach and ammonia can create chloramine gas.
Bleach mixed with an acid such as in toilet bowel cleaners produces chlorine gas.
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5. The following statement is TRUE about Phosgene gas inhalation:
a. Phosgene always produces severe respiratory effects immediately.
b. Phosgene is considered to be a highly water soluble gas.
c. Plasma phosgene levels are not clinically useful.
d. Antibiotics are useful for treating bronchospasm produced by phosgene.
e. Oxygen therapy is not useful for inhalation injury.
5. C - Plasma phosgene levels are not clinically useful. Monitor arterial blood gases, pulmonary function, and chest x-ray for patients with significant exposure.
The other choices are incorrect:
a. Severe pulmonary toxicity may be delayed, although rare, for 24 to 72 hours and include choking, chest tightness, severe dyspnea, pulmonary edema, cough, production of foaming bloody sputum, nausea, and anxiety.
B. Phosgene is considered to have low water solubility.
D. Treat bronchospasm with beta2 agonist and corticosteroid aerosols.
E. For inhalation injury: move patient to fresh air. Monitor for respiratory distress. If coughing or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer oxygen and assist ventilation as required. For acute lung early use of PEEP and mechanical ventilation may be needed.
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Fun Phosgene Facts:
1. Phosgene is a major industrial chemical used to make plastics and pesticides.
2. At room temperature (70°F), phosgene is a poisonous gas.
3. With cooling and pressure, phosgene gas can be converted into a liquid so that it can be shipped and stored. When liquid phosgene is released, it quickly turns into a gas that stays close to the ground and spreads rapidly.
4. Phosgene gas may appear colorless or as a white to pale yellow cloud. At low concentrations, it has a pleasant odor of newly mown hay or green corn, but its odor may not be noticed by all people exposed. At high concentrations, the odor may be strong and unpleasant.
5. Phosgene was used extensively during World War I as a choking (pulmonary) agent. Among the chemicals used in the war, phosgene was responsible for the large majority of deaths.
6. Phosgene gas is heavier than air, so it would be more likely found in low-lying areas.
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signs and symptoms of phosgene exposure
During or immediately after exposure to dangerous concentrations of phosgene, the following signs and symptoms may develop:
1. Coughing
2. Burning sensation in the throat and eyes
3. Watery eyes
4. Blurred vision
5. Difficulty breathing or shortness of breath
6. Nausea and vomiting
7. Skin contact can result in lesions similar to those from frostbite or burns
8. Following exposure to high concentrations of phosgene, a person may develop fluid in the lungs (pulmonary edema) within 2 to 6 hours.
Exposure to phosgene may cause delayed effects that may not be apparent for up to 48 hours after exposure, even if the person feels better or appears well following removal from exposure:
1. Difficulty breathing
2. Coughing up white to pink-tinged fluid (a sign of pulmonary edema)
3. Low blood pressure
4. Heart failure
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1. Which one of the following is NOT generally associated with muscle relaxant toxicity?
a. Hyporeflexia
b. Respiratory depression
c. Decreased consciousness or coma
d. Hypothermia
e. Metabolic acidosis
```
1. E - Metabolic acidosis is usually not seen.
* Skeletal Muscle Relaxants primarily produce CNS depression, lethargy, confusion, muscle weakness, hyporeflexia, hypothermia, coma, cardiac conduction disturbances, and anticholingeric effects in overdose.
329
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2. Which of the following is associated with hepatotoxicity in chronic use?
a. Baclofen
b. Dantrolene
c. Carisoprodol
d. Cyclobenzaprine
e. Orphenadrine
```
2. B – Dantrolene - muscle relaxer. Also used to treat and prevent malignant hyperthermia.
A number of cases of hepatitis associated with therapeutic use of dantrolene have been reported. Fatal cases were associated with the following: patient age over 30 years, duration of use over 2 months, female gender, higher daily doses (300 mg or more), concomitant drugs and disease, and higher bilirubin levels.
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3. Which statement below regarding muscle relaxant overdose is TRUE?
a. Orphenadrine has direct CNS depressant effects.
b. Carisoprodol works by strong inhibition of peripheral cholinergic receptors.
c. Blood levels are necessary in determining treatment options.
d. Dialysis is an effective and proven option in serious toxicity.
e. Physostigmine is a reversible inhibitor of acetylcholinesterase.
3. E - Physostigmine (Antilirium) is a reversible inhibitor of acetylcholinesterase. This allows for an increase of acetylcholine at the receptor sites. Physostigmine was once a widely used antidote for the treatment of atropine overdose and other anticholinergic toxicity. However, reports describing the association of physostigmine with asystole and seizures in severe tricyclic antidepressant poisoning resulted in a decrease in use.
The other choices are incorrect:
a. orphenadrine (Norflex) has direct cardiotoxic effects not direct CNS depressant effects.
b. carisoprodol (Soma) works by its metabolite meprobamate.
c. blood levels are not necessary in determining treatment options because they don’t correlate with toxicity.
d. typically, supportive care is used. Hemodialysis might be useful in severe cases of carisoprodol where the meprobamate level is very high.
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4. Which of the following symptoms is NOT seen with cyclobenzaprine (Flexeril) toxicity?
a. Coma
b. Ataxia
c. Tachycardia
d. Seizures
e. Diminished sweating
```
4. D - Seizures are not seen with cyclobenzaprine toxicity, in contrast to with orphenadrine (Norflex) which can produce seizures within two hours. Cyclobenzaprine toxicity is due to its central cholinergic blocking effects and peripheral anticholinergic effects.
332
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5. Which of the following skeletal muscle relaxants produces a CNS depression similar to barbiturates?
a. Baclofen
b. Cyclobenzaprine
c. Orphenadrine
d. Carisoprodol
e. Dantrolene
```
5. D - Carisoprodol (Soma) is metabolized to meprobamate and produces CNS depression similar to barbiturates.
The other choices are incorrect:
a. Baclofen: Lethargy and confusion are common effects. In severe oral or intrathecal overdose the following could occur: coma, seizures, respiratory depression, bradycardia, hypotension, and rarely conduction disturbances and dysrhythmias may develop.
b. cyclobenzaprine (Flexeril): is a centrally-acting skeletal muscle relaxant structurally related to amitriptyline. Classic anticholinergic symptoms predominate (tachycardia, delirium, hallucinations, warm, dry, flushed skin, urinary retention, decreased bowel sounds, dry mucous membranes). Coma, hypotension, respiratory depression, and dysrhythmias have occurred with severe overdose. Conduction defects and seizures have not been reported but might occur in severe overdose because of structural similarity to the tricyclics.
c. orphenadrine (Norflex): Patients with mild overdoses may develop typical anticholinergic effects such as mydriasis, tachycardia, agitation, confusion, hallucinations, urinary retention, and decreased gastrointestinal motility. With more severe overdoses, hypotension, ventricular dysrhythmias, respiratory depression, protracted seizures and hypoglycemia may develop.
e. dantrolene: is a centrally acting muscle relaxant whose primary toxic effect is CNS depression and in severe cases coma (used to treat malignant hyperthermia).
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1. Which statement about carbon monoxide is FALSE?
a. The primary cause of toxicity results from carbon monoxide binding to hemoglobin and decreasing available oxygen.
b. Children may be more susceptible due to a relatively lower hemoglobin content.
c. The early symptoms may be nonspecific and resemble a "flu-like" illness.
d. The fetus is less likely to suffer from CO poisoning exposure in the pregnant woman due to protective mechanisms present in the mother.
e. Neurological symptoms are commonly seen.
1. D - Fetal hemoglobin is more sensitive to binding of carbon monoxide. In the fetus the carboxyhemoglobin levels may be twice as high as maternal levels.
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2. A high priority for a patient in coma from carbon monoxide poisoning would include the following:
a. Providing 3 liters of oxygen by nasal prongs
b. Providing GI decontamination
c. Administer corticosteroids for respiratory distress
d. Monitoring the urine for crystals
e. Consulting with a hyperbaric oxygen chamber
2. E - Consulting with a hyperbaric oxygen chamber is a high priority for a patient in coma from carbon monoxide poisoning.
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3. Which of the following diagnostic studies should NOT be recommended by the specialist in poison information when consulted about the patient with smoke inhalation?
a. ABG
b. Calcium level
c. Electrocardiogram
d. Carboxyhemoglobin level
e. Methemoglobin level
```
3. B - A Calcium level would not be necessary. The other tests are useful to measure and can help guide management.
336
4. In the management of the patient with smoke inhalation, which of the following statements is TRUE?
a. Smoke inhalation victims usually deteriorate slowly following liver toxicity and do not require any early respiratory support.
b. History alone can guide the clinician to appropriate treatment of the victim.
c. Corticosteroids are effective in the management of smoke inhalation.
d. Ideal management of isolated smoke inhalation is aggressive fluid resuscitation.
e. In the comatose patient who has smoke inhalation, nitrite therapy is always useful.
4. A - A major pitfall in managing a patient with smoke inhalation is failure to appreciate the potential for rapid deterioration. These patients may need early intubation if CNS depression, visible burns, edema of the oropharynx, stridor, full thickness circumferential burns to the neck or full thickness burns to the lips and nose. B. History alone is not a sufficient guide to the clinician for appropriate treatment of the victim. Laboratory assessment including ABG, pulmonary tests, carboxyhemoglobin level, chest x ray, EKG and other tests based on clinical findings are necessary. c. Corticosteroids are effective in the management of refractory acute asthma but are not used in smoke inhalation. D. Aggressive fluid management is not the key management of smoke inhalation. E. For smoke inhalation patients, nitrite therapy is useful when cyanide toxicity is suspected. Otherwise it is not indicated.
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5. Which of the following symptoms is NOT typical in a patient who presents with smoke inhalation?
a. Upper airway obstruction
b. Bronchospasm
c. CNS stimulation
d. Hypoventilation
e. Impaired oxygen delivery
```
5. C - CNS depression would be more typical than CNS stimulation.
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1. A 12 year old female was walking through the field to her home and was bitten on her left ankle by a snake. The snake was not identified, but copperheads had been seen in the area. She complained of immediate pain and the area was swelling prior to the family contacting the poison center.
Which recommendation should NOT be advised by the specialist in poison information?
a. Remove any constricting items.
b. Wash the area thoroughly with soap and water.
c. Do not apply a tourniquet if minor envenomation.
d. Apply ice packs to reduce the swelling.
e. Evaluation of the bite should be made by an ED physician.
1. D - Ice packs are not advised to reduce the swelling. Cryotherapy, packing the area in ice or submerging the area in ice water, is not recommended. Experimentally it has shown no benefit and may increase local tissue destruction and prolong disability. There is a high rate of amputation in snake victims treated with cryotherapy.
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2. Which characteristic is NOT consistent with the physical make up of the poisonous pit viper?
a. Fangs
b. Elliptical pupils
c. Single row of scales at caudal plate
d. Pit
e. Oval shaped head
```
2. E - An oval shaped head is consistent with a non poisonous snake. Poisonous snakes usually have triangular heads. The other features of a poisonous snake include: fangs, elliptical pupils, single row of scales at caudal plate and pits.
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3. Which of the following statements is TRUE concerning the characteristics of a rattlesnake?
a. Local effects usually develop only after several hours of envenomation.
b. Ecchymosis does not occur.
c. Swelling is not noted.
d. Muscle fasciculation can occur.
e. Cardiovascular collapse has not been reported.
3. D - Muscle fasciculation can occur. Local tissue injury includes puncture(s), pain, edema, erythema, sometimes local bleeding, ecchymosis, and lymphangitis, bleb formation, tissue necrosis and sloughing. Systemic venom effects may include hypotension and shock, respiratory failure, mental status changes, obtundation and fasciculation. Less severe systemic effects include weakness, light-headedness, sweating or chills, perioral and/or peripheral paresthesias, taste changes, nausea, vomiting, and diarrhea. Fatal envenomations are rare and usually preventable. Coagulopathy - thrombocytopenia, prolongation of PT or PTT, decreased fibrinogen and/or elevated fibrin split products, may develop usually without evidence of hemolysis. Gastrointestinal bleeding, hematuria, bleeding from gingivae or venipuncture sites, and widespread ecchymosis may develop in severe cases.
341
4. Which statement concerning polyvalent crotalidae antivenin is FALSE?
a. Administration is preferably by the IV route.
b. A patient should be skin tested with the intent that antivenin is definitely going to be administered.
c. In severe envenomations, antivenin may be given even after 24 hours from the time of the bite.
d. Pregnancy is a contraindication to administration of the antivenin.
e. The dose of antivenin administered to children is not based on weight.
4. D - Pregnancy is NOT a contraindication to administration of the antivenin.
342
5. A 10 year old child was bitten on the left hand by a cottonmouth snake. Envenomation warranted the use of polyvalent crotalidae antivenin. The child was immediately skin tested for sensitivity to horse serum. Within 3 minutes erythema developed at the skin test site. The treating physician decided to borrow some CroFab from another institution because it is safer to use. This physician contacts the Poison Center regarding some information about the use of CroFab. Which statement about CroFab is TRUE?
a. CroFab has been approved for the management of patients with only severe North American rattlesnake envenomation.
b. Early use (within 6 hours of snakebite) is recommended to prevent clinical deterioration and the occurrence of systemic coagulation abnormalities.
c. Reconstitute each vial of CroFab with 10 ml sterile water for injection USP and mix by gentle swirling. It can be readily infused without further dilution.
d. The diluted product is stable for a long time and can be administered up to two weeks if necessary after preparing.
e. The recommended initial dose is 1-2 vials.
5. B - is true. Early use (within 6 hours of snakebite) is recommended to prevent clinical deterioration and the occurrence of systemic coagulation abnormalities.
a) CroFab has been approved for the management of patients with minimal or moderate North American rattlesnake envenomation.
c) The contents of the reconstituted vials should be further diluted in 250 mL of 0.9% Sodium Chloride USP before infusion. d) The diluted product should be used within 4 hours. e) Recommended initial dose is 4 to 6 vials, contingent on individual patient's response. The dose is infused at a rate of 25 to 50 mL/hr over 10 minutes. The patient is observed for any allergic reaction. If none occur then the remainder of the initial dose is infused over 60 minutes.
343
1. A 36 year old female presents to the emergency department one hour after ingesting 30 fluoxetine 10mg capsules. Which of the following is most useful for gastrointestinal decontamination:
a. Syrup of ipecac
b. Activated charcoal
c. Lavage
d. Whole bowel irrigation
e. Cathartic
2. Which symptom is NOT characteristic of the serotonin syndrome?
a. Agitation
b. Confusion
c. Constipation
d. Tremor
e. Hyperreflexia
1. B - Activated charcoal would be useful because this is a toxic dose. Fluoxetine can produce sedation so ipecac would be contraindicated. Lavage is less effective than activated charcoal. Whole bowel irrigation is not indicated because it is not a sustained release preparation. Cathartics are not indicated.
344
```
2. Which symptom is NOT characteristic of the serotonin syndrome?
a. Agitation
b. Confusion
c. Constipation
d. Tremor
e. Hyperreflexia
```
2. C - Constipation
* Serotonin syndrome (SS) occurs in patients who take serotonergic drugs such as meperidine and fluoxetine.
Serotonin Syndrome is characterized by clinical findings of at least three of the following:
1. Mental status changes
(e. g. confusion, hypomania, agitation, anxiety).
2. Neuromuscular abnormalities
(e. g., incoordination, myoclonus, hyperreflexia, tremor, confusion, delirium, hallucinations, seizures).
3. Autonomic Nervous System Malfunction
(e. g. tachycardia, hypertension, hyperthermia, mydriasis, diaphoresis, shivering, diarrhea or fever).
345
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3. A patient presented to the emergency department exhibiting manifestations of serotonin syndrome. He was just prescribed a new medication, sertraline, with his other medication.
Which medication could interact to cause this syndrome?
a. Chlorpheniramine
b. Phenylzine
c. Acetaminophen
d. Hydrochlorothiazide
e. Diazepam
```
3. B - Sertraline is an SSRI that can interact with phenylzine (Nardil, Nardelzine) - an MAOI - to produce SS. SS most commonly occurs when SSRIs are taken in combination with monoamine oxidase inhibitors (MAOIs) - either with therapeutic use or in overdose settings. Other drugs that may precipitate SS include cyclic antidepressants, dextromethorphan, pseudoephedrine, amphetamines, cocaine, lithium, LSD, buspirone, meperidine, venlafaxine, tramadol and L-tryptophan. The syndrome may even develop after a latent period.
346
4. Which statement concerning the selective serotonin reuptake inhibitors (SSRIs) is FALSE?
a. The SSRI’s differ from other antidepressants in that they appear less likely to induce dysrhythmias and seizures.
b. Cardiotoxicity noted with the tricyclic antidepressants is not frequently seen.
c. GI distress is a prominent feature in an overdose.
d. Due to the large volume of distribution, hemodialysis is unlikely to be of benefit.
e. Patients maintained on SSRIs therapeutically, commonly experience a withdrawal syndrome when the drugs are abruptly discontinued.
4. C - CNS effects including ataxia, sedation and coma are common in overdose.
347
```
5. Which antidepressant is NOT classified as a selective serotonin reuptake inhibitor (SSRI)?
a. Fluoxetine (Prozac)
b. Clomipramine (Anafranil)
c. Paroxetine (Paxil)
d. Sertraline (Zoloft)
e. Fluvoxamine (Luvox)
```
5. B - Clomipramine (Anafranil) is a cyclic antidepressant, not an SSRI.
348
```
1. Which one of the following corticosteroids is most potent in terms of its anti- inflammatory property?
a. Hydrocortisone
b. Prednisolone
c. Triamcinolone
d. Betamethasone
e. Prednisone
```
1. D - Betamethasone
* The relative anti-inflammatory potencies of these drugs are: cortisone 0.8; prednisolone 4; triamcinolone 5; betamethasone 25; prednisone 4
349
2. In regard to chronic corticosteroid exposure, which of the following is FALSE?
a. Long-term ingestion can cause hypertension
b. May develop osteoporosis
c. May cause psychosis
d. Corticosteroid levels are clinically useful
e. May develop cataracts
2. D - Corticosteroid levels are not clinically useful.
350
```
3. Corticosteroids are NOT involved in which of the following:
a. Fat redistribution
b. Protein catabolism
c. Gluconeogenesis
d. Insulin production
e. Carbohydrate metabolism
```
3. D - Corticosteroids are not involved in insulin production. Rather, they cause peripheral insulin resistance which can result in elevation of glucose levels.
351
4. Which of the following below is FALSE regarding anabolic steroids use?
a. Parenteral steroids may be detectable for up to 3 months or longer.
b. It is associated with behavior changes.
c. Hepatotoxicity is dose and duration dependent.
d. Elevation in liver enzymes is frequently seen with hepatotoxicity.
e. It is not associated with withdrawal syndrome.
4. E - Withdrawal syndromes from anabolic steroids are described in the medical literature.
352
5. In the setting of acute corticosteroids exposure, which of the following is TRUE?
a. Large oral ingestion is life threatening.
b. Pulse IV therapy has been associated with arryhythmias.
c. Emesis is generally recommended.
d. Cathartics are generally recommended for decontamination.
e. Growth retardation will develop in children after acute overdose.
5. B - High dose intravenous “pulse” therapy has been associated with dysrthymias as atrial fibrillation, asystole, myocardial infarction and sudden death.
353
```
1. Which of the following symptoms is NOT characteristic of opioid withdrawal?
a. Hypertension
b. Tachycardia
c. Tachypnea
d. Hypothermia
e. Anxiety
```
1. D - Hypothermia
| * Fever is reported with opioid and alcohol withdrawal.
354
```
2. Delirium tremens (DTs) is an extreme form of withdrawal from alcohol or sedative-hypnotics. Which of the following symptoms is NOT characteristic of DTs?
a. Confusion
b. Agitation
c. Tachycardia
d. Diaphoresis
e. Hypothermia
```
2. E – Hypothermia
* DT’s usually indicates severe withdrawal; severe withdrawal may cause fever. “Delirium tremens” was originally described as the “distinct clinical condition characterized by psychomotor, speech, and autonomic overactivity, disorientation, confusion, disordered sense perception, and frequently fatal outcomes.”
355
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3. In treating a patient with withdrawal symptoms from a sedative-hypnotic, which of the following substances will help in the management of withdrawal?
a. Chlorpromazine
b. Ethanol
c. Diazepam
d. Methadone
e. Paraldehyde
```
3. C - Diazepam would be the most useful
a - Antipshychotic drugs may increase risk of seizures
b - Ethanol should not be used to treat withdrawal symptoms.
d - Methadone is used for opioid withdrawal.
e - Paraldehyde is outdated therapy for alcohol withdrawal.
356
4. Which statement is TRUE concerning the benzodiazepine withdrawal syndrome?
a. Flumazenil is a useful therapy.
b. Severe manifestations have not been associated with benzodiazepine withdrawal.
c. Symptoms of benzodiazepine withdrawal are often over in 12-24 hours.
d. Onset of manifestations often vary depending on the elimination of the agent.
e. Methadone is useful for therapy.
4. D - Onset of manifestations often vary depending on the elimination of the agent. Factors that contribute to the severity of withdrawal include a shorter half-life
357
5. Which of the following is NOT a reasonable approach to the patient withdrawing from alcohol?
a. Administer long-acting benzodiazepines or barbiturates.
b. Correct nutritional deficits.
c. Stimulate patient to keep awake through withdrawal period.
d. Monitor fluid and electrolyte status.
e. Administer IV ethanol.
5. E - The goal is to keep the patient calm and safe, while meeting nutritional and fluid needs. IV ethanol should not be given.
358
```
1. The poison center is consulted by the emergency department in regards to the most appropriate treatment for seizure control in a patient who was accidentally overdosed with topical lidocaine.
Which medication should NOT be recommended for seizure control?
a. Phenobarbital
b. Phenytoin
c. Diazepam
d. Lorazepam
e. Pentobarbital
```
1. B - Phenytoin (Dilantin) could worsen dysrhythmias
359
```
2. An 18 month old female on arrival to the emergency department was seizing, apneic and centrally cyanotic with a palpable irregular bradycardia at a rate of 60 beats per minute. Blood pressure was unattainable. It was suspected she had ingested some type of topical anesthetic. The specialist in poison information should recommend which medication for the first line treatment of bradycardia?
a. Procainamide
b. Atropine
c. Cardioversion
d. Verapamil
e. Disopyramide
```
2. B - Atropine is the initial drug of choice for bradycardia
360
```
3. The following substance has been frequently associated with producing methemoglobinemia:
a. Xylene
b. Carbamazepine
c. Olanzepine
d. Cocaine
e. Benzocaine
```
3. E – Benzocaine.
* It is postulated that benzocaine may be metabolized to aniline, which is then transformed to phenylhydroxylamine and nitrosobenzene, both methemoglobin-forming compounds. The most common cause of methemoglobinemia is ingestion or skin exposure to an oxidizing agent.
361
```
4. Methemoglobinemia is the major toxic potential of benzocaine overdose. Which symptom is NOT consistent with this overdose?
a. Headache
b. Nausea
c. Bradycardia
d. Dyspnea
e. Lethargy
```
4. C - Tachycardia is the response seen with methemoglobinemia.
362
```
5. The antidote for methemoglobinemia is:
a. Lidocaine
b. Benzocaine
c. Atropine
d. Pyridoxine
e. Methylene blue
```
5. Methylene blue (MB) is indicated for methemoglobinemia (Methb).
Action level:
> 20% in symptomatic patients (HA, nausea, tachycardia, dyspnea, lethargy).
> 30 % in asymptomatic patients.
*Cyanosis occurs at 10-15% and is not an indication.
363
```
1. Which of the following is the most effective technique for removal of theophylline when plasma serum concentrations are 80-90 mcg/ml and the patient is hemodynamically stable?
a. Gastric lavage
b. Peritoneal dialysis
c. Charcoal hemoperfusion
d. Single dose activated charcoal
e. Alkaline diuresis
```
1. C - Charcoal hemoperfusion would be the most effective, however, it is often not used because activated charcoal given in multiple doses is almost as effective, easier to administer and safer.
* Update: In the past, hemperfusion has been recommended. However, few facilities currently offer hemoperfusion and current dialysis membranes provide theophylline clearance rates similar to those provided by hemoperfusion.
Note:
Theophylline has been used as a brochodilator for asthma and COPD and is commonly used to treat neonatal apnea of preterm infants.
364
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2. A common laboratory change noted in the acutely poisoned patient with theophylline toxicity is:
a. Hyperkalemia
b. Hypoglycemia
c. Respiratory acidosis
d. Metabolic acidosis
e. Hypocalcemia
```
2. D - Metabolic acidosis. The other choices are incorrect:
a. Hypokalemia is seen not hyperkalemia.
b. Hyperglycemia is seen not hypoglycemia
c. Respiratory acidosis and hypocalemia are not seen.
365
3. Signs/symptoms of Theophylline overdose
3. Increase in catecholamine levels (epinephrine and norepinephrine) cause tachycardia, hypotension, anxiety, hyperglycemia, hypokalemia and metabolic acidosis. Adenosine receptor antagonism may cause seizures.
366
4. Treatment of Theophylline overdose
5. No antidote. Supportive care. Benzos for seizures.
Multi-dose activated charcoal may be considered.
Dialysis is the treatment of choice. Consider dialysis early, if the plasma theophylline concentration approaches 40-60 mcg/mL in CHRONIC overdose, or 80-100 mcg/mL in ACUTE intoxications and/or significant s/s (hemodynamic compromise, seizures, mental status changes).
367
```
3. A patient exhibiting hypotension from vasodilation is not responding to conventional fluid therapy.
Which of the following agents would be the LEAST appropriate?
a. Dopamine
b. Norepinephrine
c. Epinephrine
d. Phenylephrine
e. Isoproterenol
```
3. E - Isoproterenol is not advised because of the potential for vasodilation which could produce hypotension.
368
4. Which of the following situations is NOT an indication for charcoal hemoperfusion?
a. Symptomatic patients (refractory seizures, dysrhythmias, or altered mental status) with levels above 60 mcg/ml.
b. Patients with a single acute ingestion, whose serum theophylline level is above or approaching 90-100 mcg/ml, even if the patient is not severely symptomatic.
c. Patients with respiratory failure, congestive heart failure, or severe liver disease whose serum theophylline level is above 40 mcg/ml.
d. Asymptomatic patient whose serum theophylline concentration is 30 mcg/ml after chronic overdose.
e. Massive overdoses with sustained released theophylline preparations.
4. D - All of the choices could be considered serious enough for advising charcoal hemoperfusion except for D because the patient is asymptomatic. Observation would be first choice and if patient became symptomatic or levels started to rise could advise activated charcoal and give in multiple doses if necessary.
369
```
1. All of the following clinical manifestations can be seen following a pediatric acute ingestion of levothyroxine, EXCEPT:
a. Tachycardia
b. Hyperactivity
c. QRS widening
d. Fever
e. Flushing
```
1. C - QRS widening is not seen. Clinical signs of toxicity include signs of adrenergic stimulation, such as agitation, sweating, tachycardia, hypertension, diarrhea, vomiting, and cardiovascular collapse as a result of high output failure.
370
2. Which statement is TRUE regarding toxicity from thyroid preparations:
a. Levothyroxine produces a rapid onset of effects (within minutes)
b. T4 products produce effects in an hour.
c. Liothyronine produces effects in several hours.
d. T3 products produce effects in an hour.
e. Natural or desiccated thyroid can produce toxicity within 5-7 days.
2. E - Natural or desiccated thyroid is virtually nontoxic producing effects in over 6 grains or 360 mg. Onset of toxicity within 5-7 days.
a. Levothyroxine will give delayed toxicity starting 3-4 days to 1 week postingestion.
b. T4 will give delayed toxicity starting 3-4 days to 1 week postingestion.
c. Liothyronine will produce toxic effects within 24 hours (usually within 3-4 hours).
d. T3 will produce toxic effects within 24 hours (usually within 3-4 hours).
371
3. Which of the following statements concerning ingestion of levothyroxine is TRUE?
a. Gastric emptying is probably not warranted in ingestions of less than or equal to 3 mg of levothyroxine.
b. T3 and T4 levels cannot be used to confirm ingestions of thryoid preparations
c. Toxicity is a result of adrenergic blocking.
d. Signs of toxicity usually develop within 30 minutes of ingestion.
e. None of the above.
3. A - gastric emptying is probably not warranted in ingestions of less than or equal to 3 mg of levothyroxine.
* Levothyroxine is a synthetic version of T4
* liothyronine (Cytomel) is a synthetic version of T3
b. The thyroid hormones do not correlate well with clinical effects. If high T4 values, >25ug/dL, (normal reference 4-12 ug/dL) 6 hours after ingestion suggest daily clinical assessment for 10 days as the toxicity may develop on conversion to T3.
c. Toxicity is a result of adrenergic stimulation - not adrenergic blocking
d. T4 will give delayed toxicity starting 3-4 days to 1 week postingestion and T3 will produce toxic effects within 24 hours (usually within 3-4 hours) whereas a combination of T3 and T4 may have early and delayed toxicity.
372
```
4. Which of the following is NOT considered useful in the management of a severe thyroid overdose?
a. Hemodialysis
b. Exchange transfusions
c. Propranolol
d. Plasmaphoresis
e. External cooling
```
4. A - Hemodialysis is not useful because of the extensive protein binding.
b/d. Plasmapheresis and exchange transfusion may be effective in the rare life threatening situation.
c. Propranolol which produces beta blockade may be used for control of adrenergic symptoms. It prevents T4 to T3 conversion. Simple tachycardia may be managed with oral propranolol, severe tachydysrhythmias by IV route.
e. External cooling would be useful if "thyroid storm" (tachycardia, hypertension, hyperthermia) develops which is a very unusual occurrence. In addition, treat with oxygen, corticosteroids, propylthiouracil, oral iodide, propranolol and IV fluids.
373
```
1. Which of the following essential oils characteristically can cause seizures in toxic amounts?
a. Melaleuca oil
b. Cinnamon oil
c. Sandalwood oil
d. Camphor
e. Menthol
```
1. D - Camphor is a rapidly acting neurotoxin with both excitatory and depressant properties. Less than 10 mg/kg is unlikely to cause seizures; gastrointestinal irritation and sedation occur at 10-30 mg/kg, significant toxicity has not been reported with less than 30 mg/kg.
a. melaleuca oil. Few human cases of poisoning have been reported in the medical literature. Coma for 12 hours, followed by semiconsciousness for 36 hours, has been reported in an adult. Confusion and incoordination have occurred in a child. Dermatitis can occur following ingestion and/or skin contact. Based on information about terpenes and volatile oils, CNS depression, vomiting, and seizures may occur if sufficient amounts are ingested.
b. cinnamon oil. Most case reports deal with exposures through food or cosmetics. Besides being a mucous membrane irritant, cinnamon oil is a strong allergen, causing various types of allergic reactions. CNS depression has been reported.
c. sandlewood oil. There is little published information regarding the toxicity of this essential oil. Expected effects include mucous membrane irritation or numbness, gastrointestinal irritation, dermal irritation and hypersensitivity.
d. menthol. Severe nausea, vomiting, abdominal pain, vertigo, ataxia, drowsiness and coma are the most commonly reported symptoms of overdose. Menthol is the major toxic constituent of peppermint oil.
374
```
2. Which of the following clinical effects is NOT seen with an exposure to essential oils?
a. Mucous membrane irritation
b. CNS depression
c. Vertigo
d. Tachycardia
e. Respiratory alkalosis
```
2. E - Respiratory alkalosis. There is little published information regarding the toxicity of essential oils. Expected effects include mucous membrane irritation or numbness, gastrointestinal irritation, dermal irritation and hypersensitivity. CNS depression or stimulation may occur.
375
```
3. Which of the following essential oils can cause salicylate toxicity?
a. Camphor
b. Oil of wintergreen
c. Eucalyptus
d. Eugenol
e. Menthol
```
3. B - Oil of wintergreen, 1 ml of oil of wintergreen (methyl salicylate) = 1,400 mg of aspirin. A single teaspoon (5 ml) of methyl salicylate contains approximately 6 g of salicylate.
* Local salicylate referral > 300 mg/kg
376
4. Which of the following statements regarding para-aminobenzoic acid (PABA) is NOT true?
a. Human overdose data on PABA or its esters is rare.
b. Symptoms are unlikely with normal pediatric exposures.
c. A metallic taste is often seen with ingestions.
d. Cardiac failure is a commonly reported symptom.
e. Current therapy should be directed at controlling symptoms of gastritis, hepatitis and photodermititis.
4. D - Cardiac failure is not a commonly reported symptom. Symptoms are unlikely with normal pediatric exposure. Since some PABA sunscreens contain 50% or more ethanol, ethanol toxicity may be the greater risk for those products. PABA ester overdose data is even more meager than PABA itself, but these esters do not appear to be more toxic. Metallic taste is often reported with ingestion. In one human fatality and in animal experiments, cardiac failure and fatty changes of the myocardium have been noted. Nausea, vomiting and abdominal cramps are often reported with oral therapy. Hepatitis and jaundice may be noted, and have occurred with PABA doses of 3 to 20 g/day. Nephritis and other renal changes are an inconsistent finding. Leukopenia has been reported with therapeutic doses of 48 g/day. Photodermatitis and pruritus are rare, but possible, effects with PABA or its esters. Hypoglycemia and glycosuria have been reported in both animal and human exposures.
377
```
5. What potential problem can be associated with ingestions of essential oils, since they may contain various fats, waxes, or emulsifiers?
a. Metabolic acidosis
b. Aspiration pneumonia
c. Increased anion gap
d. Increased coagulapathy
e. None of the above
```
5. B - Aspiration pneumonia may occur because essential oils may contain various fats, waxes, or emulsifiers.
378
1. Which of the following ingredients commonly found in over the counter vitamin preparations can cause papilledema when taken in excess?
a. Vitamin C
b. Vitamin D
c. Vitamin B6
d. Vitamin A
e. Vitamin E
1. D - Vitamin A.
* Vitamins taken in large or “mega” doses can cause adverse effects:
B6:
Excessive doses of vitamin B6 can produce difficulty in walking and tingling sensations in the legs and soles of the feet. Continued megadoses of vitamin B6 result in further unsteadiness, difficulty in handling small objects, and numbness in the hands.
Vitamin D:
Acute toxicity effects from overdosage of vitamin D may include muscle weakness, apathy, headache, anorexia, nausea, vomiting, and bone pain.
Vitamin C:
Effects may include renal colic (ie, nephrolithiasis) and diarrhea. Acute toxicity effects include headache, nausea, vomiting, drowsiness, and desquamation after 24 hours.
Vitamin A:
Chronic toxicity affects the skin, mucous membranes, and the musculoskeletal and neurological systems. Skin and mucous membrane effects include erythema, eczema, pruritus, dry and cracked skin, conjunctivitis, palmar and plantar peeling, and alopecia. Musculoskeletal effects include pain and tenderness, particularly in the long bones of the upper and lower extremities, which may be exacerbated by exercise; epiphyseal capping and premature epiphyseal closure may occur in children. Neurological effects include frontal headache and blurred vision. Findings also include papilledema, hepatomegaly, ascites, erythematous dermatitis, or bulging fontanelle in infants.
379
```
2. Which vitamin is contained in a preparation that has proven useful in treating the paresthesias which can result from exposure to a pyrethrin insecticide?
a. Vitamin A
b. Vitamin C
c. Vitamin D
d. Vitamin E
e. Vitamin B12
```
2. D - Vitamin E
* Paresthesias are a common finding after dermal exposure to a pyrethrin insecticide. Oil of vitamin E preparations appear effective for treatment of paresthesias as long as they contain vegetable oils such as corn oil sesame oil, safflower oil or wheat germ oil.
380
1. Which of the following agents causes a cholinergic syndrome?
a. Phosgene oxime
b. Chlorine
c. Mustard gas
d. Soman
e. T-2
1. A - Soman
a. Phosgene oxime, while classified as a vesicant, does not truly produce vessication like mustard and lewisite.
b. Chlorine is a pulmonary agent capable of producing effects in both the central and peripheral areas of the bronchial tree.
c. Mustard gas is a vesicant.
d. Soman (GB), is one of the “German” agents initially discovered while investigations into new insecticides were being conducted. Discovered in 1944, Soman is a lethal agent that exerts its effects through inhibition of acetylcholinesterase. This inhibition results in an overstimulation of receptors by acetylcholine. The resulting symptoms are a result of interaction with both muscarinic and nicotinic receptors. The wide ranging effects of nerve agents are a result of muscarinic and nicotinic receptors being found throughout the body.
e. T -2 toxin is a mycotoxin, a compound that belongs to the trichothecene class. apidly and completely absorbed from the gastrointestinal tract and quickly distributed to all major organs. The mechanism by which T-2 toxin causes cell death is through the inhibition of protein synthesis at the 80S ribosome.
381
```
2. Exposure to hydrogen cyanide would be expected to cause all of the following symptoms EXCEPT
a. Metabolic acidosis
b. Cyanosis
c. Cherry red skin
d. Hyperpnea
```
2. B - Cyanosis
* Cyanide exerts its effects by interfering with electron transport and impairing oxidative phosphorylation. The effects seen are the result of an inability of cells to utilize oxygen. While cyan or cyano means blue and we generally associate a lack of oxygenation with cyanosis, the cyanide poisoned patient does not exhibit cyanosis unless it is very late in the course of the patients decline. Cherry red skin seen in the cyanide poisoned patient is a result of excess venous saturation. Initially, hyperpnea is noted as the body attempts to increase the amount of oxygen in the bloodstream. Metabolic acidosis is seen in patients exposed to cyanide. As a result of a switch from aerobic to anerobic metabolism, organic acids like lactic acid accumulate and contribute to acidosis. As a result of cyanides interference with the electron transport system, unincorporated hydrogen ions accumulate and the result is metabolic acidosis.
382
3. Muscarinic cholinergic symptoms of nerve agent exposure may be reversed by administration of which of the following
a. Amyl nitrite
b. N-acetylcysteine
c. 2-pralidoxime chloride
d. Atropine
3. D - Atropine
a. Amyl nitrite is the first ingredient used in the civilian cyanide antidote kit. Amyl nitrite has been removed from the military version of the kit. Amyl nitrite is given by inhalation and is used to induce methemoglobinemia. This is done because there is a greater affinity of cyanide for methemoglobin than for cytochrome oxidase. While cyanide is exerting its effects in the cell, cellular respiration is impaired. Cells have access to circulating oxygen in the bloodstream but cannot utilize it. Methemoglobin is present in the body normally in a few % concentration. In excessive levels hypoxic symptoms can occur due to an inability of the red blood cells to transport oxygen as efficiently as they could if the methemoglobin state was not present.
b. Acetaminophen toxicity is treated with N-acetylcysteine.
c. 2-pralidoxime chloride (2-PAM) is one of many oximes that can be used to treat the nicotinic manifestations of nerve agent exposure. These oximes work to remove the nerve agent from acetylcholinsterase so that the acetylcholinesterase can resume its normal function in the synapse of breaking down acetylcholine. These agents are effective if aging has not occurred. Aging is a process whereby the bond between the nerve agent and the acetylcholinesterase enzyme changes and becomes irreversible. Once aging occurs, there is no possibility that the acetylcholinesterase/agent bond can be broken by any means. The aging time for soman is 2.5 minutes, 3 to 4 hours for tabun, and approximately 48 hours for VX. Since acetylcholinesterase is regenerated by the body at a rate of 1-2% per day, it is very important that appropriate therapy with 2-PAM be initiated as soon as possible when it is indicated.
d. Atropine is indicated for use to reduce the muscarinic symptoms related to nerve agent exposure. Atropine endpoints in the nerve agent poisoned patient include a reduction in chest tightness resulting in a greater ease of ventilation and decreased shortness of breath. Another endpoint in atropine therapy is the reduction of secretions produced as a result of the nerve agent exposure. Atropine endpoints should not include heart rate changes, papillary changes, or a reduction of twitching or fasciculation.
