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Tox Flashcards

1
Q

dosing of opiod overdose

A

naloxone (narcan)
starit with 0.04mg for adults and 0.1mg/kg kids

if no increase in RR in 2-3min –> increased to 0.5mg –> 2mg –> 4mg –> 10mg –> 15mg

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2
Q

management of sympathomimetic overdoses

A

benzos 1st line

antipsychotics if pts still agitated

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3
Q

difference betweeen sympathomimetic toxidrome vs antimuscarinic

A

sympathomimetics has sweating

antimuscarinic has dry mucosal membranes

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4
Q

sources of antimuscarininc toxidromes

A

Quetiapine, TCAs carbamazepine, jimson weed, oxybutinin, diphenhydramine

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5
Q

clinical features of antimuscarinic toxidrome

A 
(mad hatter, dry as a bone, etc...)
AMS
mydriasis 
urinary retention
ileus 
tachy
anhidrosis (dry)
mumbling speech
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6
Q

antidotal therapy for antimuscarinic toxidrom

A

physostigmine (mod-sev) 0.5-2mg IV (not to exceed 1mg/min)

tx: agitation (benzo)
wide complex tachy (Na bicarb)
cool blankets, IVF

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7
Q

contraindications to physostigmine

A 
bradycardia
av block 
severe asthma
allergy to it or salicylate 
mechanical obstruction GU orGI
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8
Q

muscarinic toxidrome

A

pilocarpine, mushrooms, organophosphates

DUMBELLS (diarrhea, urination, miosis, brady, bornchorrhea, emesis, lacrimation, sweating

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9
Q

tx of muscarinic toxidrome

A

atropine given until bronchorrhea resolves
start 0.5-2mg Q5min

pralidoxime

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10
Q

sedative overdose management

A

supportive care
Flumazenil for benzo toxicity
phenobarb elimination enhance with urinar alk (Na bicarb infusion) and/or hemodialysis

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11
Q

which syndrome has lead pipe rigidity

A

NMS
vs
Serotonin syndrome has hyperreflexitivity

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12
Q

presentation of serotnonin syndrome

A 
clonus 
hyperreflexia 
lower extremity rigidity 
diarrhea
shivering 
tremor 
diaphoresis
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13
Q

tx of serotonin syndrome

A

benzos 1st line
cyproheptadine in refractory cases

dantrolene for rigidity

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14
Q

NMS

A

90% in 1st week of new med

AMS, hyperthermia, tachy, lead pipe rigidity, bradykinesia, rhabdo

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15
Q

tx of NMS

A

benzos
bromocriptine in refractor cases

dantrolene for rigidity

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16
Q

indications for emergency dialysis

A 
acidosis
electrolytes 
intoxications 
overload 
uremia
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17
Q

dialyzable drugs

A

salicyclates
toxic alcohols
lithium
INH

metformin
theophylline
atenolol

topiramate
acyclovir
phenorbabital

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18
Q

Common indications for charcoal

A 
cyanide 
cyclic antidepressants 
CCBs
colchicine 
mushrooms
cocaine 
aspirin
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19
Q

contraindications to using charcoal

A

iron
lithium
arsenic

methanol
ethanol
ethylene glycol

strong acids or bases

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20
Q

almond odor

A

cyanide poisoning - burning nitrites, pesticides, nitroprusside

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21
Q

carrot smells

A

water hemlock - cicutoxin water vegetation

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22
Q

garlic breath

A

organophosphates
arsenic
selenium

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23
Q

mothballs scent

A

camphor - topical pain cream

naphthalene - insecticide

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24
Q

wintegreen

A

methyl salicylate

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25
rotten egg scent
sulfur dioxide | hydroge sulfide
26
mc toxin ingested in US
acetaminophen
27
when does acetaminophen toxicity develop in an acute single ingestion
>150mg/kg up to 200mg/kg in kids <8yrs old
28
levels obtained prior to 4hrs
<100mcg/ml between 2-4hrs = (-) 100% <100cg/ml between 1-2hrs = (-) 97% >300mcg/ml at any time = tx needed
29
NAC
72hr course if PO 21hr if IV
30
presentation of salicylates overdose
- tachy - resp alk due to tachpnea - n/v/gastritis - met acid - ketoacidosis
31
management of salicylate overdose
- IVF w/ LR - urinary alkalinization is key - Goal serum pH 7.45-7.55 with urine pH >7.5
32
how to achieve urinary alkalinization
bolus na bicar 1-2mEq/kg prn target pH followed by infusion
33
how to prepare nabicarb infusion
add 3ampules of na bicarb and 40mEq K+Cl to 1L of D5W infuse at 150-250ml/hr
34
hemodialysis indications for salicylate overdose
- renal failure - worsening acidosis or rising levels despite aggressive tx - AMS - level >100mg/dL
35
end organ toxicity of acute salicylate toxicity <150mg/kg (mild)
tinnitus hearing loss dizziness n/v
36
end organ toxicity of acute salicylate toxicity 150-300mg/kg (mod)
``` tachypnea hyperpyrexia diaphoresis ataxia anxiety ```
37
end organ toxicity of acute salicylate toxicity >300mg/kg (severe)
``` AMS seizures acute lung injury renal failure cardiac arrhythmias shock ```
38
clinical features of NSAIDs overdose
``` >400mg/kg gastritis met acidosis ams tachy seziures AKI ```
39
tx of NSAID overdose
supportive LR>NS sucralfate for gastritis
40
opiod overdoses associated with seizures
tramadol propoxyphene meperidine
41
opiods associated with cardiotoxicity including QT prolongation
methadone** loperamide propxyphene
42
amides vs esters
amids = lidocaine, bupivacine, prilocaine esters = tetracaine, benzocaine, cocaine (amides = 2 i's and esters = 1 i in their name)
43
toxic dose of lido w/ and w/o epi
with epi = 7mg/kg, 1% 10mg/ml, 2% 20mg/ml, max 500mg w/o epi = 5mg/kg, max 300mg 1% 10mg/ml, 2% 20mg/ml
44
toxic dose of bupivicaine w/ and w/o epi
w/ epi = 3-5mg/kg (max 225) 0.5% sol = 5mg/ml w/o epi = 1.5-3mg/kg (max 175mg)
45
management of QRS widening
boluses of sodium bicar 1-2mEq/kg q5min until QRS interval responds or pH ?7.55
46
management of QT prolongation
mag sulfate 50mg/kg x1 empirically K needs to be >4.5
47
causes of methemoglobinemia
benzocaine, dapsone, nitrites, metoclpraide nitrobenzne, aniline dyes, trinitrotoluene
48
chocolate blood on venipuncture think
methomglobinemia measure via co-oximetry to confirm dx tx - methylene blue 1-2mg/kg reduces Methb to hemoglobin (renders pulse ox meaningless for a few min
49
when is methylene blue contraindicated
G6pd def | if methylene blue is unavailable treat with blood transfusion
50
acute toxicity of warfarin can lead to
- elevated INR above range - calciphylaxis in pts w/ ESRD leading to thrombi formation - skin necrosis within first 10 days typically in obese middle aged women w/ protein C def
51
tx of warfarin toxicity
INR <5 w/ no sig bleed = hold next dose or lower daily dose INR 5-9 w/ no sig bleed = hold next 1-2 doses and consider vit K INR >9 w/ no sig bleed = hold coumadin and give vit K Serious bleed at any INR = hold coumadin give vit K and FFP or >> PCC (better)
52
reversal agent for dabigatran
idarucizamab and also hemodiaysis can help eliminate dabigatran
53
alteplase reversal agent
amiocproic acid
54
enoxaprin and unfractionated heparin reversal agent
protamine sulfate
55
toxicity signs for CCBs
``` bradycardia hyperglycemia ileus bowel infarction hypotension ```
56
management of CCBs toxicity
IVF Ca gluconate 1-2g IV NE and EPi high dose insuline(esp for verapamil and dilt) bolus insulin 1unit/kg and then start infusion 1u/lg/hr
57
Beta blocker toxicity presentation
bradycardia hypotension QRS widening and/or QT prolongation (propanol, sotalol) hypoglycemia, seizures
58
tx of beta blocker toxicity
glucagon traditionally (ADR n/v) now IVF, and manage hypotension with pressors Na bicarb for QRS >120ms, 1-2 mEq/kg q5min until its narrowed or pH >7.55
59
clonidine toxicity presentation
CNS depression hypotension bradicardia MIosis seizures, hypothermia (less common)
60
management of clonidine toxicity
supportive IVF for BP naloxone for CNS depression (may need high doses)
61
Digoxin toxicity presentation
bradydysrhythmias (acute) tachydysrhythmias (chronic) Hyper K >5 (50% mortality if no tx), >5.5 (100% mortality if no tx) Visual disturbances (perceived flashes of light, abnormal colored vision) Gi symptoms, weakness
62
Digoxin toxicity EKG
bidirectional v tach and paroxysmal atrial tachy with block scooped/scagging ST segment (salvador dali mustache)
63
tx of digoxin toxicity
``` supportive digoxin Fab fragments if: K >5 dig level >15 any time dig level >10 ( >5hrs post ingest) progressive bradydysrhthmias severe ventricular dysrhythmias ingestion >4mg kid ingestion >10 adult ```
64
what can falsely elevated dig levels
digoxin Fab so once given dig levels dont mean anything but a free digoxin concentration can be used if available
65
classes of antidysrhythmics
Simply Block the Proper Channel ``` I = Sodium II = beta adrenergic III = Potassium IV = Calcium ```
66
chronic amiodarone toxicity may include
thyroid dysfunction pneumonitis corneal microdeposits skin discoloration
67
ACE inhibitors ADR and notes
hyperkalemia hypotension cough angioedema transient Cr bump monitor in pts with renal issues
68
Losartan (angiotensin II receptor blocker) ADR and notes
hyperkalemia hypotension cough monitor in renal pts
69
loop diuretics ADR and notes
ototoxicity (high doses) hypokalemia hypomag monitor electrolytes and orthostatics
70
thiazide diuretics ADR and notes
hypokalemia hypo Na volume depletion monitor electrolytes and orthostatics
71
spironolactone (K sparing) ADR and notes
hyper K | gynecomastia
72
amiodarone ADR and notes
QT prolongation hepatotoxicity pulm fibrosis thyroid toxicity Hypotension w/ rapid infusion
73
diltiazem and verapamil (nondihydropyridine CCB) ADR and notes
hypotension AV block (esp when combined with beta blockers) bradycaria CYP3A5 substrates
74
amlodipine (dihydropyridine CCB) ADR and notes
hypotension | edema
75
uses for metoprolol vs esmolol
metoprolol (Afib) esmolol (short acting aortic dissection
76
what pts should you avoid using clopidogrel on
active bleeding | pts with stroke hx or TIA
77
heparin dose adjustments
not necessary in renal dysfunction Ok during pregnancy
78
enoxaprin dose adjustments
dose reduction in renal dysfunction pts Ok during pregnancy
79
presentation of phenobarbital toxicity
CNS depression resp depression (occasionally) hypotension bradycardia
80
management of phenobarbital toxicity
supportive urinary alkalinization (bicar bolus and infusion) hemodialysis
81
phenytoin toxicity presentation typically chronic due to zero order elimination
cerebellar signs (ataxia, nystagmus and dysmetria) IV - cardiotoxic/seziures elimination can be enhanced by hemodialysis
82
carbamazepine toxicity presentation
CNS depression cerebellar signs seizures, cardiotoxc (QRS widening and QT prolongation) antimuscarininc toxicity
83
management of carbamazepine toxicity
cardiotoxic w/ Na bicarb and/or mag seizures w/ benzos physostigmine for antimuscarininc consider hemodialysis for levels near 40mcg/ml
84
topiramate toxicity presentation
CNS depression cerebellar signs normal gap acidosis hypo K hyper Cl seizures
85
management of topiramate toxicity
replace K w/ potassiu phosphate or K acetate benzos for seizures hemodialysis
86
valproic acid toxicity presentation
``` CNS depression QT prolongation elevated AST and ALT Pancreatitis Bone marrow suppression ``` hypotension hyper ammonemia less common seizures
87
management of valproic acid toxicity
if soon after overdose -> charcoal * L carnitine indicated in AMS pts and w/ elevated levels - -> dose 50-100mg/kg followed by 25-50mg/kg q6hrs until VPA level <100 naloxone for CNS dep hemodialysis - >500mcg/ml
88
TCA toxicity
- QRS widening from Na channel poisoning - QT prolongation due to K efflux blockade tachy or brady (severe) hypotension sedation, antimuscarinic tox, seizures, serotonergic tox
89
management of TCA toxicity
QRS widening w/ Nabicarb 1-2mE1/kg q5min until QRS interval resolved or pH >7.55
90
management of refractory hypotension w/ TCA toxicity
NE or Epi Dopamine is contraindicated (can exacerbate hypotension)
91
SSRI toxicity
tachycardia GI symptoms (mc) CNS depression QRS widening and/or QT prolongation (citalopram) hyperreflexia
92
bupropion toxicity
can take >24hrs seizures tachy, CNS depression QRS wid and/or QT pro
93
management of bupropion toxicity
Gi decontamination with single dose activated charcoal or whole bowel irrigation
94
lithium toxicity
GI signs predominate Neuro signs serum level correlates w/toxicity
95
management of lithium toxicity
whole bowel irrigation aggressive fluid resuscitation w/ NS hemodialysis if concomitant renal insufficiency
96
normal lithum level
0.6-1.2
97
ADR of clozapine
agranulocytosis weight gain hyperglycemia myopathy
98
EKG finding of atypical antipyschotics
QT prolongation (although rare)
99
ADHD stimulant toxicity
tachy, HTN, diaphoresis mydriasis, agitation seizures tx - supportive, benzos for szs
100
sulfonylureas toxicity and management
hypoglycemia >12hrs later GI decontamination supp dextrose + octreotide - preferred antidote (safer than glucagon) dose = 1mcg/kg IV/SQ 16hrs prn
101
metformin toxicity and management
sig lactic acidosis in pts w/ risk factors: ckd or chronic liver dz tx - supp hemodialysis if: rising lactate levels, renal insuff w/ hyper K
102
ondansetron (zofran) ADR
qt prolongation at doses >32mg
103
prochlorperazine ADR
sedation antimuscarinic toxicity miosis, rhabdo cardiotoxicity
104
management of prochlorperazine
tx cardiac and antimuscarinic tox as usual lipid emulsion in massive overdose
105
metoclopramide toxicity
CNS depression QT prolongation methemoglobinemia extrapyramidal signs tx like the rest
106
what is the risk of allergic rxn to 1st and 2nd gen cephalosporins in PCN allergic pts
1% and the risk for 3rd and 4th gen cephalosporins = negligible
107
fluoroquinolones ADR
QT prolongation associated with tendinopathy (esp in elders)
108
macrolides (azithro) ADR
QT prolongation large doses cause sensorineural hearing loss CYP 4500 3A4 inhibition chronic use = hepatitis
109
tetracyclines (doxy) ADR
pill esophagitis photosensitivity occasionally nephrotoxic hepatotoxic
110
ADR of vanc
red man syndrome
111
INH toxicity
CNS depression seizures metabolic acidosis hepatitis
112
antidote for INH
pyridoxine dose should be equivalent to ingested
113
Antimalaria toxicity
GI symptoms, tinnitus CNS depression, seizures, dysrhythmias, rnela fialure QRS wide, QT prol, hypotension
114
acyclovir toxicity
AMS seizures nephrotoxicity
115
nucleoside reverse transcriptase inhibitors ADR
lactic acidemia zidovudine - hematologic toxicity pancreatitis
116
dextromthorpan ADR
dissociation | large ingestion -> serotonin toxicity - AMS, tachy, hyperthermia, clonus, hyperreflexia, diarrhea
117
management of dextromethorphan toxicity
supp care benzos cyproheptadine dantrolene for rigidity
118
antihistamine toxicity
sedation, (antimuscarinic) AMS, tachy anhidrosis, mydriasis ileus, urine retention rhabdo and cardiotoxicity
119
management of anthistamine toxicity
cardio tox like usual szs w/ benzos antimuscarinic w/ physostigmine consider lipid emulsion in massive overdose
120
signs of alcohol withdrawal
tremor, restlessness hallucinations (visual>auditory) seizures DTs (48-96hrs)
121
management of alcohol withdrawal
diazepam and chlordiazepoxide (long acting) benzos (ineffective in malnourished pts) and failure mcc underdosing
122
methanol toxicity (wiper fluid, carburetor cleaner, etc)
mild inebriation elevated methanol level wide gap acidosis ocular signs -> lesions in putamen hyperglycemia and pancreatitis (less common)
123
ethylene glycol toxicity (antifreeze)
mild-mod inebriation wide gap acidosis AKI w/ hypo Ca CN palsies (less common)
124
management of ethylene glycol toxicity
if early - fomepizole is sufficient if late - hemodialysis
125
isopropyl alcohol toxicity (rubbing alcohol)
significant inebriation gastritis ketosis but NO acidosis Hypotension CNS depression
126
chronic stimulant use is associated with
vasculitis cardiomyopathy pulm HTN valvular injury
127
when should flumazenil be avoided
in pts who have ingested a proconvulsant xenobiotic aka: TCA, tramdol or buprpion
128
how can phenobarbital elimination be enhanced
hemodialysis and urinary alkalinization
129
carbon monoxide toxicity
greater affinity for Ox than Hgb (pulse ox - false nml) "flu w/o the fevere" HA, N, confusion dyspnea, chest discomfort rhabdo dysrhthmias, MI, Sz, Coma,
130
dx and tx of CO toxicity
measuring COHb via co-oximetry tx - 100% oxygen reduces half life of COHb
131
CN toxicity
rapid unconsciousness seizures acidosis cardio tox arterialization (bright red blood)
132
tx of CN toxicity
supp care antidotal therapy with amyl nitrite and sodium nitrite (avoid in smoke inhalation) sodium thiosulfate IV hydroxocobalamin IV (HTN and skin discoloration are temporary ADR)
133
hydrogen sulfur toxicity (flammable colorless gas)
smells like rotten eggs but high levels olfactory paralysis irritation of skin and mucus membranes ha, vomiting, szs, coma cardiovascular instability
134
tx of hydrogen sulfur toxicity
supp | nitrites (weak evidence)
135
insecticide toxicity
``` DUMBELS defecation urination miosis bradycardia bronchospasm bronchorrhea emesis lacrimation salivation ```
136
iron toxicity
``` sign toxic >60mg/kg GI phase (first 6hrs) - vomiting and/or diarrhea Latent phase - look better but developing tox at cellular level Shock + Acidosis phase ```
137
management of iron toxicity
consider whole bowel irrigation deferoxamine indicated for pts with signs and symptoms + serum level >450mcg/dL - dose 15mg/kg until iron level therapeutic or sym resolved - - ADR hypotension give Fluids and may predispose pts to yersinia infections
138
lead toxicity
abd pain, anemia, acute liver injury, encephalopathy chronic - anorexia, weight loss, constipation, HTN, anemia, nephrotoxic, CNS issues
139
dx and tx of lead toxicity
dx - whole blood lead level tx - supp, chelation therapy if indicated, dimercaprol, CaEDTA, and succimer whole bowel irrigation (for large acute ingestion)
140
arsenic toxicity
gastroenteritis that may be hemorrhagic hypotension, tachycardia metabolic acidosis, AMS, rhab neuropathy, pancytopenia chronic: BMS, peripheral neuropathy, pvd, portal HTN, skin disorders
141
common skin finding for arsenic poisoning
spots of hyperkeratosis and hyperpigmentation on the palms and soles seen in chronic arsenic poisoning
142
dx and tx of arsenic toxicity
dx - 24hr urine arsenic levle tx - supp, chelation therapy if indicated w/ dimercaprol, unithiol, succimer whole bowel irrigation (large acute ingestions)
143
hydrofluoric acid toxicity | rust remover, glass etching supplies
local mucus membrane irritation bronchospasm corneal injuries hypo Ca, Mg hyper K QT prolongation
144
management of hydrofluoric acid toxicity
``` decontamination, supp supplemental Ca - topical Ca for burns or Ca gluconate 10% solution 0.2-0.4mL/kg IV for systemic toxicity ```
145
caustic toxicity (toilet bowel cleaner, bleaches, car batteries, gun bluing agents)
alkalis cause liquefactive necrosis acids cause coagulative necrosis mucus membrane and skin irritation, pneumonitis
146
management of caustic injuries
DONT INDUCE EMESIS endo for pts w/ resp distr, hematemesis, stridor, vomiting, drooling GI decontamination except for zinc Cl and cationic detergents
147
hydrocarbon toxicity (essential oils, gas, lighter fluids, solvents)
bronchospasm, pneumonitis (avoid albuterol see below) skin damage, GI injury, CNS effects (lead to leukoencephalopathy) Sensitize myocardium
148
antimuscarinic plants
jimson weed | atropa belladonna
149
nicotinic plants
poison hemlock tobacco mydriasis, tachy, weakness, HTN, szs, sweating
150
water hemlock
causes status epilepticus by antagonizing GABA receptors may require high doses of benzos
151
castor bean toxicity
disrupts protein synthesis inhibiting 28S subunit of the ribosome producing significant GI symptoms and multi organ failure tx - spp care, fluid resus
152
death cap mushroom (amanita phalloides)
cause of 95% mushroom deaths stage 1 - GI phase (6-12hrs) stage 2- liver damage, elevated transaminases and bili, coagulopathy, hepatic encephalopathy (2-3days) stage 3- liver and renal failure (death in 3-7days)
153
management of death cap mushroom toxicity
activated charcoal if presentation is 1-2hrs spp care with fluid and electrolyte resus NAC (IV) PCN (high dose IV) OTC raw milk
154
stone fish
dyspnea, spasticity hypotension, tachycardia vomiting, abd cramping tx - spp care, local wound care, HOT water immersion (45C) 30-60min and anti-venom
155
stingrays envenomation presentation
sig pain and concomitant trauma vomiting, syncope seizure, hypotension heart failure
156
tx of stingray envenomation or injury
spp care, local wound care HOT water immersion (30-60min) infection in 13% of cases so prophylactic abx should be given
157
cnidaria (jelly fish, portuguese man o war, anemones) | presentation
pain, papular lesions local tissue injury vomiting seizures hypotension cardiovascular collapse death
158
management of cnidaria injury
spp care inactive nematocyts w/ vinegar for 30 min (**except for American Sea nettle, mauve stinger and lions mane jellyfish) control pain w/ parenteral narcotics and hot water immersion 45C (30-60min)
159
scombroid presentation
develops when histidine gets decomposed by bacteria to histamine causing flushing and gastroenteritis (within min)
160
fish that are associated with scombroid
TUNA mackerel mahi mahi albacore, bonito, skipjack, blue fish
161
management of scombroid poisoning
H1 and H2 antagonists albuterol and occasionally epi for the tx of bronchospasm
162
Ciguatera toxin fish species
GROUPER sea bass barracuda parrot fish sturgeon
163
presentation of ciguatera toxin following large consumption
2-6hrs later: temperature reversal HA, diaphoresis brady hypotension vomiting, abd cram, profuse diarrhea sensation of loose teeth
164
management of ciguatera toxin
spp care | gabapentin
165
tetrodotoxin (TTX) species pathyophys tx
blue ringed octopus pufferfish TTX blocks Na channels -> paresthesia, weakness, dysphagia, hypotension, brady and flaccid paralysis (6-24hrs) tx - spp care, neostigmine (possibly)

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