TOX Flashcards
1
Q
When should poisoning be on the ddx
A
- Patient with ALOC – no obvious cause
- Inexplicable vital signs
- Inexplicable lab tests, EKG
- Symptoms look like a toxidrome
- Multiple patients w/ same sx’s
2
Q
focused Hx with poisoning should focus on
A
Known, suspected or reported ingestion/exposure? 1. Anticipate: What class of substance was ingested? What does it (they) do?
3
Q
mngmt of poisoning should involve
A
v. REVERSE with antidote, if possible
vi. REMOVE residual poison, if possible
vii. NEUTRALIZE circulating poison
viii. ENHANCE ELIMINATION of the poison
4
Q
poison control number
A
1-800-411-8080
5
Q
initial mangement of tox pt
A
ii. Breathing - O2 Sat, RR – effectively ventilating?
iii. Circulation – BP low or high?
iv. Cardiac rhythm? Tachy? Brady? Wide or narrow? Is it changing?
v. D & E is for Disability/Decontamination/Exposure
6
Q
why is considering who called 911 important
A
did the person who ingested this want to be saved
7
Q
other important hx question
A
when was it taken why etoh or alcohol PMH has this ever happened before
8
Q
physical exam
A
i. Vital signs
ii. Cardiac rhythm – do they have a dysrhythmia?
iii. Level of consciousness, gag reflex
iv. Pupils - size and reactivity
v. Skin signs – sweaty, dry, hot, rash, track marks
vi. Bowel sounds – hyper-, hypoactive, are they present at all?
vii. Bladder distention
viii. Breath/body odor
ix. Evidence of trauma, focal
9
Q
bowel sounds
A
toxidrome predictable of medicines
10
Q
management of tox
A
• D-stick, EKG, Upreg right away
• IV access, monitor, O2
• Acetaminophen (APAP) level
• Chem, CBC, UA, Blood
EtOH, Utox
11
Q
why do you want to get a cmp
A
anion gap, electrolytes, renal, LFT’s),
12
Q
get drug levels
A
- Digoxin
- Dilantin (ataxia; OD of Dilantin will make you not able to walk; they have a broad based ataxia like “drunk walking”), Carbamazepine, Valproic Acid
- Lithium
“Comprehensive” drug screens not helpful – take too long
13
Q
• “Coma Cocktail”
A
- 50 cc of 50% glucose IV: (“Amp of D50”)
* Naloxone (Narcan®
14
Q
• Naloxone (Narcan®)
A
reverses an opioid OD immediately. Narcan lasts about 45 mins. So if their OD is with a longer acting agent then they will come back for the 45 mins, the narcan wears off and they will go down again. Put soft restraints b/c they will wake up UNHAPPY, combative, and irritable
• 0.8-2 mg IN, IM, IV
15
Q
when would you get a KUB
A
• KUB for select, ingested radiopaque substances
16
Q
special labs you may need to order
A
- Calcium, Magnesium
- Total CK (rhabdomyolysis)
- PT/INR (hepatotoxic, coumadin)
- Serum osmolarity/osmolar gap
17
Q
methods of removal
A
decontamination
• HAZMAT, protection for HCP
• Forced emesis**
• Surgical removal
18
Q
Forced emesis**
A
b/c concerned about airway complications and esophageal rupture so don’t use this method
Rare: no syrup of ipecac
19
Q
how do you neutralize
A
• 1 gm / kg administered orally • Repeat dosing for some drugs • Give with cathartic (Sorbitol) • Can be given pre-hospital • Not always useful, can be dangerous Antidote: known ingestion/exposure
20
Q
ENHANCE ELIMINATIONhis look like and what do we use
A
- Whole bowel irrigation
* Go-Lytely - Dialysis, Hemofiltration
- Enhance urinary excretion
usually reserved for people who have ingested packets of drugs
21
Q
i. Opiates tx
A
naloxone
22
Q
ii. Acetaminophen tx
A
– N-acetylcysteine
1. NAC, Mucomyst
23
Q
iii. Digoxin
A
– Digibind Fab-fragments
24
Q
iv. Benzos -
A
flumazenil
25
v. Cyanide
- Lilly kit
26
vi. INH –
– pyridoxine
B6?
27
Carbon Monoxide
vii. Carbon Monoxide – oxygen
28
• Anticholinergics -
physostigmine
29
• Cholinergics
atropine, 2-PAM
30
• Beta blockers
glucagon (increases force and rate of contraction – chronotropic and ionotropic)
31
Ca channel blockers - TX
calcium
32
TricyclicsTX
Na bicarbonate
33
• Metals -TX
chelating agents
34
• Iron TX
deferoximine
35
• Warfarin (Coumadin TX
): Vitamin K
• Over-anticoagulation common
• Hold dose, check bleeding
36
Causes of osmolar gap
1. Methanol
2. Ethylene glycol
3. Ethanol
4. Isopropyl alcohol
5. Others....
37
normal anion gap
Calculated
| 1. Normal = <10
38
AG calculation
Na) – (Chloride + TCO2); Normal 5-15
39
Things that show up on a plane film
* Chloral hydrate
* Heavy metals
* Iron
* Phenothiazines; Packets of drugs (body packers)
* Enteric coated pills
* Salicylates
40
charcoal does not work on these
* Iron
* Lithium
* Cyanide
* Pesticides
* Acids and alkalis
41
why would you give someone charcoal in a NG tube
losing airway is not good with this
| black slurry
42
what are toxidromes
predictable effects of particular medication
43
Anticholinergic toxidrome
a. Mad as a hatter
b. Blind as a bat
c. Red as a beet
d. Dry as a bone
e. Hot as hell
2. Flushed, dry skin
3. Elevated temp, pulse
4. Agitated delirium
5. Hallucinations
6. Dilated pupils
7. Seizures
8. ABSENT BOWEL SOUNDS
9. Distended bladder
44
what medications cause anticholinergic SE
```
Benadryl
scopolamine
atropine
TCA
carbamazepine
flexaril (muscle relaxer)
plants
```
45
plants that cause anticholinergic SE
Jimson Weed, Belladonna
46
support for anticholinergic
a. Supportive: IV fluids, monitor
b. Charcoal, Benzo’s
c. Don’t sedate with antipsychoticà enhances anticholinergic effectà seizure, sicker
d. Critical? Physostigmine
47
Cholinergic toxidrome
SLUDGE
i. Salivation
ii. Lacrimation
iii. Urination
iv. Diaphoresis
v. GI upset
vi. Emesis
b. Bradycardia ,Wheezing
c. Constricted pupils (pinpoint)
d. Lethargy
48
what can cause a toxidrome
* Pesticides
* Organophosphates
* Chemical Warfare agents
* Sarin, VX, etc
49
Tx fro cholinergic toxidrome
* Decontamination, supportive
* Atropine – muscarinic effects
* Pralidoxime (2-PAM) – both muscarinic and nicotinic effects
50
Cholinergic tx
* Decontamination, supportive
* Atropine – muscarinic effects
* Pralidoxime (2-PAM) – both muscarinic and nicotinic effects
51
sympathomemetic toxidrome
GO SPEED RACER
* Elevated BP, pulse, temp
* Can be really high
* Agitated delirium
* Seizures
* Dilated pupils
* Normal skin or sweating
* normal bowel sounds
* Bladder not distended
52
sympathomemetic drugs
* Cocaine, Amphetamines, Ecstasy
* Multiple formulations
* Caffeine
* Pseudoephedrine, Ma Huang (ephedra)
* Ritalin, Adderall, diet pills
53
sympathomemtic vs anticholinergic
NORMAL BOWEL SOUNDS
| BLADDER NOT DISTENDED
54
sympathomemtic tx
a. IV fluids, Benzo’s, cooling
b. Control VS
c. Charcoal, Go-Lytely if ingested packets
55
classic triad of opiate toxidrome and 2 others
* Depressed LOC
* Lethargy to coma
* Decreased respirations (4)
* Pinpoint pupils (miosis)
* Hypotension
* Pulmonary edema
56
opiates that cause sxs
* Heroin, methadone
* Morphine, Dilaudid, Meperidine (Demerol)
* Fentanyl - patches
* Codeine, Hydrocodone, Oxycodone
57
special opiates
* Lomotil
| * Dextromethorphan
58
v. Serotonergic (Serotonin Syndrome) usually happens as a result of
• Most common w/ dose increase, addition of another to tx or overdose
59
Serotonergic toxidrome
* Agitated or comatose
* Elevated temperature, pulse
* Hypo- or hypertension
* Normal pupils
* Normal skin signs
* Increased reflexes
* Clonus -hold it and bounce
* “Wet dog” shakes
60
Serotonergic meds
* SSRI’s, SSNRI’s, MAOI’s
* SSRI’s + triptans
* Combo with pain meds
61
Serotonergic treatment
a. Withdraw offender, supportive
| b. Benzo’s
62
Doesn’t fit a toxidrome? consider
i. Mixed ingestion/exposure
ii. Head trauma
iii. Infection
iv. Shock
v. Metabolic imbalance
** meningitis is possible
63
i. Common, silent, deadly: order level in ALL poisoned pt’s.
h. Acetaminophen
64
what levels are toxic for acetaminophem
7.5g in adults or 150mg/kg in kids is toxic
Timing of ingestion is key – 2-4hr first level
65
what is the APAP key
timing of ingestion is key – 2-4hr first level
66
what are sxs of apap
iv. Typically few sx’s first 24hrs
| v. Then: RUQ abd pain, malaise, nausea
67
labs for APAP ingestion
ASA, CBC, Chem, UA, Upreg, EKG
| ix. Serial levels every 4-6hrs depending on Hx
68
Treatment for APAP
1. Charcoal if recent
| 2. N-acetylcysteine (NAC, Mucomyst) for 72hrs
69
Aspirin – Salicylates
i. Common, acute or chronic – slowed absorption, concretions
70
Early/mild sx’s ASA
Early/mild sx’s: tachycardia, tinnitus, n/v, abd pain, tachypnea, diaphoresis
71
Late/severe ASA sxs
Late/severe: coma, seziures, resp depression, non-cardiogenic pulmonary edema, dehydration, shock
72
how does chronic ASA tox occur
concretions
big ball of ASA hard to break up
73
severity of the ASA toxicity is directly related to the
iv. Severity = acid base imbalance
74
1. Mild toxicity/first sign
alkalosis
75
2. Progression
: resp alkalosis and AG metabolic acidosis
76
3. Severe/progression
severe AG metabolic acidosis
77
labs for ASA
v. Labs: ASA, APAP, UA/Upreg, CBC, Chem, ABG, EKG, serial ASA levels
78
TX for ASA
ABC’s, IV hydration, charcoal w/o cathartic, alkalinize urine (bicarb)
79
Pt with persistent, inexplicable tachycardia?
vii. Pt with persistent, inexplicable tachycardia? Think aspirin
80
what amount of NSAIDS is toxic
ii. 100mg/kg usually benign; co-ingestion
| >400mg/kg may be life-threatening
81
NSAIDS >400mg/kgsxs
1. ALOC/coma, acidosis, seizures, pulmonary edema
82
k. Oral Hypoglycemics/Insulin sxs
i. Sx’s: ALOC, diaphoresis, tachycardia, bizarre behavior, paralysis, seizure – can mimic CVA
83
immediate dx with altered pts
ii. Immediate d-stick on ALL altered patients
84
sulfonyureas reversal
Sulfonylureas, Insulin – rapid reversal with 1 amp D50 after d-stick
85
iv. Metformin overdose
less profound hypoglycemia but lactic acidosis w/ AG present
86
The problem with oral hypoglycemics:
1. They last a long time, longer than 1 amp D50
2. Pt becomes repeatedly hypoglycemic
3. Admit these folks with glucose rich IV drips
87
Insulin OD
– admit if severe. Can correct, watch for 6hrsàhome if stable, no risks, not suicide
vii. Feed everyone with hypoglycemic toxicity
88
amitriptyline
| Nortriptyline
TCA
89
amitriptyline
| Nortriptyline TCAs toxidrome
iii. Anticholinergic toxidrome
90
ECG chnages with anticholinergics
1. First – sinus tach
2. Terminal R-wave in aVR
3. Widened QRS
4. Ventricular tachycardia
91
other than an anticholinergic and EKG changes what other sxs do you see
v. Coma, seizures, hypotension
92
what is the reversal agent
vi. Charcoal, whole bowel irrigation
93
sxs of iron overdose
ii. Nausea, vomiting, abd pain, diarrhea
94
sith suspected iron overdose need to figure out
iii. Estimate amount and which prep
95
sxs of iron overdose
1. AG metabolic acidosis
2. WBC’s >15k
3. Glucose >150
4. Serum iron test
96
what dx tests for suspected iron
KUB good – Charcoal does not work
97
vin rose
Dexferoxamime
antidote for iron
98
sxs of digoxin
2. N/V/D, bradyarrhythmias, hyperkalemia, CNS sx’s, EKG with specific findings
3. Dig level, Digibind Fab if arrhythmias
99
BB overdose sxs
1. Brady, hypotensive, ALOC, ventricular arrhythmias
100
labs for suspected digoxin overdose
3. Dig level, Digibind Fab if arrhythmias
101
BB overdose treatments
2. IV fluids, tx shock, charcoal if indicated
102
CCB tx
1. Sx’s/Tx much like Beta Blockers – add Calcium
103
read flags with alcohol overdose
1. EtOH level does not match sx’s
2. Not “metabolizing” (getting less drunk) with time
3. Trauma – do a good exam
4. GI bleeding, abd pain, n/v
5. Confusion, can’t walk
6. Jaundice, bruising
104
can't wait for chronic ETOH to get to 0
No need for zero level to d/c! Chronic etoh’ers will experience withdrawal sx’s at zero!
105
Refer for alcohol Tx
Benzo’s Rx for mild withdrawal sx’s
106
PE Signs:
* Tongue wag (fasiculations in the tongue), tremor
* Tachycardia
* Low grade temp
107
Red Flags fir alcohol withdraw
* Hallucinations, confusion
* Agitated delirium
* Seizure, asterixis
* Jaundice
108
tx for alcohol withdra
IV fluids, monitor, EKG, high vis bed
• Give thiamine IV
FEED THEM
109
LABS for alcohol withdraw
• Labs: CBC, Chem, PT/INR, Magnesium, Phosphorus
110
rx for alcohol withdrawal
* Benzo’s: Lorazepam 2-4mg IV until sx’s abate or need an airway
* Phenobarbital helps avoid Sz – long acting – give early
* IV 130-260mg q 30min until sedation or 1040mg
111
early sxs of mushrooms
iv. Early GI symptoms (w/in 2hrs) usually reassuring
112
delayed sxs of mushrooms
Delayed symptoms (>6hrs) associated with liver, kidney, CNS damage
113
labs for mushrooms
LFTSvi. Get LFT’s, coags, electrolytes, monitor closely
114
return to this slide
mushroom tx
. Amanita phalloides: delayed liver failure (day 3)
2. Amanita Smithiana: delayed renal failure (day 3)
3. Lepiota: delayed liver failure (day 3)
vii. Call Poison Control for ALL mushroom toxicity
115
onset of Rohypnol (flunitrazepam)
1. Rohypnol (flunitrazepam): pill form, illegal in U.S.
a. Sedation, muscle relaxation, amnesia
b. 15-30min onset, lasts 4-6hrs; tablets now dissolve with blue color
116
GHB (gamma-hydroxybutyric acid onset
1. 15min onset, lasts 3-4hrs, gone from body in 8hrs
| 2. Sedation, amnesia
117
ketamine
liquid/powder, onset in minutes, lasts up to 4hrs
| 1. Psychoactive, muscle paralysis, amnesia
118
OTC sedation
1. Visine (tetrahydrozoline), Afrin (oxymetazoline), others
119
peak ingestion of one pill kill
i. Peak age of ingestion is 1-3yr olds
120
one pill kill list
1. BIG ONE Calcium Channel Blockers – shock, brady arrhythmias
2. Clonidine – opiate toxidrome
3. Lomotil – opiate toxidrome
4. Sulfonylureas – hypoglycemia, seizures, coma
5. Cyclic Antidepressants – anticholinergic, dysrhythmias
6. Salicylates – same sx’s as adults – more serious
121
hypoglycemia, seizures, coma in children
sulfonylureas
122
pepto bismol
oil of wintergreen
6. Salicylates
123
Clonidine toxidrome
opiate toxidrome
124
Lomotil toxidrome
opiate toxidrome
125
carbon monozide poisoning seen most commonly
i. Common in winter months, cold climates – multiple sources
126
two major contributors to smoke inhalation deaths
ii. Major contributor to smoke inhalation deaths (cyanide too)
127
pathophys of CO poisoning
iv. CO binds to hemoglobin 200 times better than oxygen
1. Also binds to myoglobin, cytochromes P450 and AA3
v. Organs needing high O2 – brain, heart – affected
128
labs for CO poisoning
vii. Lab: carboxyhemoglobin (mild <20%, severe >40%)
| 1. Labs, lactic acid, ABG, EKG, troponin/myoglobin
129
tx for CO poisoning
viii. Tx: 100% Oxygen by non-rebreathing mask
| 1. Severe poisonings – hyperbaric oxygen chamber
130
near drowning
inhaling water
131
pathophysiology of near drowning
water causes loss of surfactant
Water swallowed, aspirated, alveolar flooding/loss of surfactant, hypoxia, lose airway reflexes, bradycardia, cardiac arrest, global CNS damage
132
better survival with cold water or warm water
cold better than warm
133
important questions for near drowning
a. Predisposing event: trauma, EtOH, hypoglycemia, seizure, MI, suicidal ideation, accidental
b. Clean or dirty water? Dove from height? Scuba diving?
134
labs for near drowning
ii. ABC’s first, CXR, +/- Head, C-spine CT, labs, CK, ABG
135
core temp <40.5 C (104.9) with normal mental status
1. Heat exhaustion
| Normal mental status, dehydrated, sweating, weak, n/v, HA
136
heat stroke sxs
va. ALOC, ataxia, dry/hot/flushed skin, +/- sweating
| b. CNS, coagulation, liver, renal damage
137
heat stroke temp
core temp >40.5 C – life threatening
138
3. Drugs associated with increased heat production
a. Cocaine, amphetamines, EtOH, salicylates
139
what do you search for with increased temp
what's tx
a. D-stick, CBC, CMP, PT/INR, CK, TSH, UA, Upreg/tox
| b. Tx: ABCDE’s, cooling (ice packs, fan/wet sheet), Tylenol or NSAIDS do not work here
140
5. Malignant hyperthermia
rare, genetic, precipitated by anesthesia drugs: muscle rigidity, rhabdo
141
osborne waves are associated with hypo or hyperthermia
hypo
142
primary hypothermia
exposure, EtOH, elderly, infants, immersion
143
Secondary hypothermia
Sepsis, trauma, CVA, endocrine
144
4. Iatrogenic hypothermia
: IV fluids not warmed, ambient temp
145
kids: mammalian diving reflex
iv. Metabolism slows – kids: mammalian diving reflex
146
multi systems involved in hypotension
1. Cardiac – gentle handling to avoid dysrhythmias
a. Tach Brady, Osborn wave on EKG
2. CNS – clumsy, confusion, shivering
147
tx for hypotension
remove/tx cause, d-stick, EKG, upreg, warm IV fluids and O2, Bear-Hugger rewarming pad, feed
148
i. Snake bites**
none proven – immobilize/transport best
| a. Keep the pt still
