Toxicologic Emergencies

Question 1

What are the routes of toxic exposure?

Answer 1

Ingestion
Common agents:
-Household products
-Petroleum-based agents
-Cleaning agents
-Cosmetics
-Drugs, plants, or foods

Inhalation
Common agents:
-Toxic gases, vapors, fumes, aerosols
-Carbon monoxide, ammonia, chlorine, Freon, nitrous oxide
-Absorption occurs via the capillary-alveolar membrane in the lungs.

Skin surface absorption
Common agents:
-Poison ivy, oak, or sumac
-Organophosphates

Injection
Common agents:
-Animal bites or stings
-Intentional injection of illicit drugs

Question 2

What are the general principles of toxicologic assessment and management?

Answer 2

Recognize a poisoning promptly.
Assess the patient thoroughly to identify the toxin and measures required to control it.
Initiate standard treatment procedures:
Protect rescuer safety
Remove the patient from the toxic environment
Support ABCs.
Decontaminate the patient.
Administer antidote if one exists.

Question 3

General Assessment:

Answer 3

Initial assessment includes:
Airway and respiratory - compromise of respirations is common in toxicological emergencies.
Identify the toxin and length of exposure.
Contact poison control and medical direction according to local policy.
Complete appropriate physical exams.
Monitor vital signs closely.

Question 4

General Treatment:

Answer 4

Initiate supportive treatment.
Emergency room interventions include stabilization of patient and often involve attempts to reduce absorption of the toxin.
Gastric lavage and activated charcoal may be utilized.
Attempts to enhance elimination of the toxin by use of hydration and poison or drug antidotes when possible.

Question 5

What are antidotes?

Answer 5

Antidotes are useful only if the offending substance is definitively known.
They are not always effective.
Must often be used in conjunction with other therapies to ensure effectiveness of treatment.

Question 6

Antidote to Acetaminophen?

Answer 6

N-Acetylcysteine (NAC)

Question 7

Antidote to Arsenic, Mercury, Gold?

Answer 7

BAL (British anti-Lewisite)

Question 8

Antidote to Atropine?

Answer 8

Physostigmine

Question 9

Antidote to Benzodiazepines?

Answer 9

Flumazenil

Question 10

Antidote to Carbon monoxide?

Answer 10

Oxygen

Question 11

Antidote to Cyanide?

Answer 11

Amyl nitrite then sodium nitrite then sodium thiosulfate

Question 12

Antidote to Ethylene glycol?

Answer 12

Fomepizole (or as methyl alcohol)

Question 13

Antidote to Iron?

Answer 13

Defreoxamine

Question 14

Antidote to Lead?

Answer 14

Edentate calcium disodium or Dimercaptosuccinic acid (DMSA)

Question 15

Antidote to Methyl alcohol?

Answer 15

Ethyl alcohol +-dialysis

Question 16

Antidote to Nitrates?

Answer 16

Methylene blue

Question 17

Antidote to Opiates?

Answer 17

Naloxone

Question 18

Antidote to Organophosphates

Answer 18

Atropine
Pralidoxine (Protopam)

Question 19

General Treatment:

Answer 19

Suicidal patients and protective custody patients must be documented as such.
Involve law enforcement.
Involve medical direction.
Know local procedures and laws as the laws for protective custody vary from state to state.

Question 20

Toxic Syndromes

Answer 20

Toxidromes include: Anticholinergic, Acetylcholinesterase inhibition, Cholinergic, Extrapyramidal, Hemoglobinopathies, Metal Fume Fever, Narcotic, Sympathomimetic, Withdrawal

Question 21

What is Cyanide signs and sxs?

Answer 21

Cyanide is a rapidly acting toxin.
It is usually ingested or inhaled and it may also be absorbed through the skin
Signs and symptoms include but are not limited to: a burning sensation in the mouth and throat, headache, confusion, combativeness, hypertension and tachycardia.
If not treated, patient may develop seizures and may go into a coma.
Ensure rescuer safety.
Initiate supportive care.
Administer antidote: Cyanide antidote kits contain amyl nitrite, sodium nitrite and sodium thiosulfate.

Question 22

Cardiac medications:

Answer 22

Commonly due to dosage errors
Signs and symptoms may include: nausea, vomiting, headache, dizziness, confusion, profound hypotension and cardiac dysrhythmias. Additional symptoms may include respiratory distress, bronchospasm and pulmonary edema.
Management involves maintaining airway and adequate perfusion and administer antidote to that drugs effects whenever possible.

Question 23

Caustic substances:

Answer 23

-Exposure typically occurs by ingestion or through contact and absorption through the skin.
-Acids can cause significant damage at sites of exposure and are often rapidly absorbed into the bloodstream.
-Alkaline agents usually have a slower onset of symptoms which may allow for longer contact and more extensive tissue damage.
-Signs and symptoms include: skin damage such as chemical (vs. thermal) burns, pain in the lips, tongue, throat or gums, drooling, trouble swallowing
Hoarseness, stridor, or shortness of breath
Shock from bleeding, vomiting
-Management
Perform standard toxicologic emergency procedures.
Maintain an adequate airway.

Question 24

Hydrocarbons:

Answer 24

Hydrocarbon containing toxins may be ingested, inhaled, or adsorbed.
Signs and symptoms may include: burns due to local contact, wheezing, dyspnea, hypoxia, pneumonitis, headache, dizziness, slurred speech, ataxia, foot and wrist drop with numbness and tingling.
cardiac dysrhythmias, obtundation and coma.
Do NOT induce vomiting!

Question 25

Salicylates:

Answer 25

Includes aspirin, oil of wintergreen. Signs and symptoms may include: tachypnea, abdominal pain, vomiting, tinnitus, pulmonary edema, ARDS hyperthermia, confusion, lethargy, coma, dysrhythmias, cardiac failure and respiratory arrest. Treatment includes I.V. hydration, alkalinization of urine and dialysis if renal insufficiency occurs.

Question 26

Acetaminophen-containing narcotic analgesics

Answer 26

Codeine/acetaminophen - Tylenol 3 or 4 Hydrocodone/acetaminophen -Vicodin, Lortab Oxycodone/acetaminophen - Percocet, Roxicet Propoxyphene/acetaminophen - Darvocet Tramadol/acetaminophen - Ultraset

Question 27

Acetaminophen (Tylenol)

Answer 27

The definitive mechanism of action of acetaminophen is not fully understood. It appears to weakly block the peripheral blockade of prostaglandin synthesis with stronger blockade of prostaglandin synthesis in hypothalamus. Acetaminophen is readily absorbed, metabolized in liver, excreted in urine. No increased risk of GI bleeding. No increased risk for development of Reye’s syndrome. Acetaminophen or Tylenol comes in the form of tablets, caplets or capsules, in doses of 325 mg, 500 mg and 650 mg. General recommended dosages 325 mg to 650 mg taken q 4. Overdose is generally considered to be any dose >7 gm/ 24 hrs or lower doses when acetaminophen is taken with alcohol. Overdose can result in severe hepatic necrosis leading to liver failure, coma and death.

Question 28

Acetaminophen toxicity

Answer 28

In acute overdose or when the maximum daily dose is exceeded over a prolonged period, the normal conjugative pathways for the metabolism of acetaminophen become saturated. Acetaminophen is oxidatively metabolized in the liver via the mixed function P450 system to a toxic metabolite, N-acetyl-p-benzoquinone-imine (NAPQI). The course of acetaminophen poisoning has been divided into 4 stages: Stage 1 – 30 minutes to 24 hrs – N/V Stage 2 – 24 to 48 hrs – may be clinically improved but liver function tests reveal rising AST, ALT, and Bilirubin levels. Stage 3 – 72 to 96 hrs – peak hepatotoxicity, AST may exceed 20,000. Stage 4 – beyond 96 hours – recovery, need for liver transplant or death.

Question 29

Acetaminophen toxicity signs and symptoms?

Answer 29

``` Stage 1 (30 mins-24 hours) - Nausea, vomiting, weakness, and fatigue Stage 2 (24-48 hours) - Abdominal pain, decreased urine, elevated liver enzymes Stage 3 (72-96 hours) - Liver function disruption Stage 4 (4-14 days) - Gradual recovery or progressive liver failure ```

Question 30

Acetaminophen toxicity treatment:

Answer 30

When acetaminophen overdose is suspected, treatment involves removal of any drug remaining in the stomach by lavage or induction of emesis with syrup of ipecac. The antidote, N-acetylcysteine, (NAC) should be administered as early as possible, preferably within 8 hours of the overdose ingestion for optimal results. NAC is theorized to work through a number of protective mechanisms. NAC is a precursor of glutathione and increases glutathione availability to bind to NAPQI. It may also enhance sulfate conjugation of any unmetabolized APAP. NAC also functions as an anti-inflammatory and antioxidant. NAC increases local nitric oxide concentrations, and this vasodilatory effect on microcirculatory blood flow enhances local oxygen delivery to peripheral tissues. These vasodilating effects decrease morbidity and mortality even in the setting of established hepatotoxicity. NAC is most effective when administered within 8 hours of ingestion. When indicated, however, NAC should be administered regardless of the time since the overdose. Therapy with NAC has been shown to decrease mortality rates in late-presenting patients with fulminant hepatic failure, even in the absence of measurable elevation of serum acetaminophen levels.

Question 31

Other nonprescription pain medications signs and sxs?

Answer 31

Nonsteroidal anti-inflammatory drugs (NSAIDs) include Ibuprofen, Naproxen sodium Signs and symptoms of overdose of an NSAID may include: abdominal pain, nausea, vomiting, drowsiness, headache, tinnitus, dyspnea, wheezing, pulmonary edema, swelling of extremities, rash and itching.

Question 32

NSAID-containing narcotic analgesics

Answer 32

Oxycodone/aspirin - Percodan Oxydodone/ibuprofen - Combunox Hydrocodone/ibuprofen - Vicoprofen

Question 33

Tricyclic antidepressants

Answer 33

Antidepressants -Include Amitriptyline, Amoxapine, Doxepin, Nortriptyline, Imipramine, Clomipramine. -TCAs have a narrow therapeutic index. Signs and symptoms of toxicity -Dry mouth, blurred vision, urinary retention, constipation

Question 34

Theophylline:

Answer 34

Theophylline is a bronchodilator that was very commonly prescribed for asthma and COPD but its use has been limited due to its very small therapeutic index. Possible signs and symptoms of overdose include: agitation, tremors, seizures, cardiac dysrhythmias, nausea, and vomiting Management may include repeated doses of activated charcoal and monitoring for and treatment of cardiac dysrhythmias.

Question 35

Antidepressants

Answer 35

Trazodone, Bupropion and SSRIs Signs and symptoms may include: drowsiness, tremor, nausea, vomiting, and tachycardia. Serotonin syndrome is marked by agitation, anxiety, confusion, insomnia, headache, coma, salivation, diarrhea, abdominal cramps, cutaneous piloerection, flushed skin, hyperthermia, rigidity, shivering, incoordinationand myoclonic jerks. Management is standard toxicologic emergency procedure.

Question 36

Tricyclic Antidepressants (2 of 2)

Answer 36

Signs and symptoms of severe toxicity Confusion, hallucinations, hyperthermia. Respiratory depression, seizures. Tachycardia, hypotension, cardiac dysrhythmias. Management Perform standard toxicologic emergency procedures. Monitor and treat cardiac dysrhythmias. Avoid use of Flumazenil, which may precipitate seizures.

Question 37

MAO Inhibitors

Answer 37

Infrequently Prescribed Antidepressant with high mortality rate with overdose. Signs and symptoms may include: headache, agitation, restlessness, tremor, nausea, severe hypertension, hyperthermia, palpitations and tachycardia. Can progresses to bradycardia, hypotension, coma and death.

Question 38

Lithium

Answer 38

Prescribed to treat bipolar disorder Narrow therapeutic index Signs and symptoms Thirst, dry mouth, tremors, muscle twitching, and increased reflexes Confusion, stupor, seizures, coma, nausea, vomiting, diarrhea, bradycardia, and dysrhythmias Treatment Standard toxicologic emergency procedures Activated charcoal not effective with lithium

Question 39

Metals

Answer 39

Iron overdose of dietary supplement Signs and symptoms: vomiting (possible hematemesis), diarrhea, abdominal pain, shock, liver failure, bowel scarring and obstruction, metabolic acidosis. Activated charcoal NOT indicated. Lead and Mercury Overdose often results from chronic environmental exposure. Signs and symptoms: Headache, irritability, confusion, coma, memory disturbances, tremors, weakness, agitation, abdominal pain. Activated charcoal NOT indicated.

Question 40

Contaminated food

Answer 40

Bacteria, viruses and toxic chemicals Bacterial exotoxins and enterotoxins Signs and symptoms: Nausea, vomiting, diarrhea, and abdominal pain, facial flushing and respiratory distress

Question 41

Contaminated food treatment?

Answer 41

Treatment Perform assessment. Collect samples of the suspect food source. Maintain the airway and support breathing. Intubate and assist ventilations if indicated. Administer high-flow, high-concentration oxygen. Establish IV access. Consider medications. Antihistamines, antiemetics.

Question 42

Poisonous plants and mushrooms

Answer 42

Decorative plants are a common source of accidental poisoning in children Signs and symptoms: excessive salivation, lacrimation, diaphoresis, abdominal cramps, nausea, vomiting, diarrhea and altered mental status Treatment: Follow treatment guidelines for contaminated food.

Question 43

Insect bites and stings

Answer 43

Insect Stings Signs and Symptoms: localized pain, redness, swelling Observe for signs of an allergic reaction. Tachycardia, hypotension, bronchospasm, laryngeal edema, facial edema, uvular swelling

Question 44

Insect bites and stings treatment?

Answer 44

Insect stings Treatment Wash the area. Remove stingers, if present. Use care not to disturb the venom sac. Apply cool compresses to the injection site. Observe for and treat allergic reactions and/or anaphylaxis.

Question 45

If you have someone who has accidental ingestion of a drug what don't you give them?

Answer 45

Don't give them any food! | sips of water okay until know they are out of danger.