toxicology Flashcards

Question

acetaminophen OD tx

Answer 1

-ABCs -activated charcoal within 8-12 hrs Antidote: !N-acetyl-cysteine (NAC)! -> Dose: 140mg/kg!, Detoxes and decrease NAPQI -Very effective when given EARLY – !within 8hrs of ingestion! -Equally effective at 1hr vs 7hrs post ingestion -still indicated in late presentations >24hrs - safe in pregnancy - charcoal does not inhibit effectiveness Dialysis (rare): severe (>1000mg/L), AMS, metabolic acidosis, elevated lactate Transplant = liver failure Discharge pt if unintentional, no hepatotoxicity, downtrending APAP levels that nontoxic after tx (<150 @ 4hrs or below nomogram)

Answer 2

-Significant reported ingestions (single ingestion >150mg/kg) -4 hour level (or more) APAP lies above the nomogram cutoff (>140mcg/mL) -APAP ingestion presenting close to the 8hr cut off -Evidence of hepatotoxicity presumed to be from APAP -A serum APAP >10mcg/mL and unknown ingestion time -There is technically no “cut off” time to start NAC

Answer 3

-NOT toxic -CNS depressant- down regulates GABA and upregulates NMDA -!intox level - 80-100mg/dL -always r/o other causes of AMS -> POC glucose, consider head CT, fx (trauma), other drugs, electrolytes, ammonia, etc. -!Ataxia, slurred speech, horizontal nystagmus, alcohol on breath (AOB) Tx- supportive

Answer 4

Wernicke- -B1 (thiamine) deficiency from chronic alcoholism and poor nutritional intake -tachy, HTN, tremor, hallucination, seizures, delirium tremens -triad = oculomotor abn (CN6 palsy), ataxia, global confusion - reversible -COAT- confusion, oculomotor abnormalities (nystagmus, CN 6 plasy), ataxia, thiamine def -tx- IV thiamine for 3 day Korsakoff syndrome: -untreated wernickes and untreated thiamine deficiency - irreversible -RACK- retrograde amnesia, anterograde amnesia, confabulation (fabricated memories to fill in gaps), korsakoff psychosis

Answer 5

benzos, booze, barbs withdrawals = fatal sx: CNS hyperexcitation -TACHYCARDIA, HTN, AGITATION - diarrhea, mydriasis, insomnia, cramps, diaphoresis, piloerection -6-12 hrs: early uncomplicated -> minor sx- anxiety, intention hand tremors that dont fatigue, tongue fasciculations, insomnia -> ASK WHY -tx- benzos -12-24hrs: hallucinosis -> hallucinations (tactile > auditory or visual) -24-48hrs: seizures -> generalized tonic-clonic convulsions -chronic alc (not binge) -r/o head trauma/bleed, poisoning, epilepsy, CNS infection, metabolic -tx- benzos only -48-72hrs: delirium tremens -> !disorientation/confusion! - must have disturbances in CONSCIOUSNESS OR COGNITION, hallucinations, hyperthermia, hyperreflexia, tachycardia, resp alk - low K and Mg and hypovolemia -mortality 5% -if A&O = not delirium tremens - tx = benzos - valium

Answer 6

Dx- CIWA score; higher score = more severe withdrawal; done hourly Tx - BENZOS: diazepam, lorazepam, midazolam, chlordiazepoxide - if severe: titrate benzo to achieve state of sedation with arousability to minimal stimulation - phenobarbital (if resistant) - propofol if intubation - clonidine: HTN, tachycardia - IV fluids with dextrose, thiamine, multivitamins, Mg replacement

Answer 7

* Ask- WHY did they stop drinking? * Tremulous, anxious, agitated * Intention hand tremor, that is constant and does not fatigue * Tongue fasciculations are more sensitive * Early as 6 hours, Peaks at 24-36 hours, resolves at 2-3 days Treatment: * Benzodiazepines * Assess readiness for rehab * Reassess with CIWA score * <8 can be managed outpatient

Answer 8

* 1-48 hours after decrease/cessation of alcohol consumption * Usually 1-6 seizure episodes * Generalized tonic-clonic w/ shorter post-ictal time (few minutes) * Prolonged seizures, localizing findings, focal seizure, or status epilepticus – look for other cause!!! * Low threshold to scan, and look for other trauma (CT head noncontrast) * Usually chronic alcoholics (not binge drinkers) Treat: - benzos to reduce recurrent AWDS - No role for antiepileptics unless hx of epilepsy

Answer 9

12-24 hrs: alcohol hallucinosis (TACTILE > auditory, visual) - feeling things that aren't there (bugs on skin) 48-72 hrs: delirium tremens - DISORIENTATION/CONFUSION** - hallucinations - hyperthermia - tachycardia - mortality up to 50%

Answer 10

* Late occurrence: 2-4 days after stopping/decreasing alcohol * 1-15% mortality rate * Symptom complex: * Must have disturbance in CONCIOUSNESS or COGNITION ** * (if they are awake and alert its not DT) * Accompanied by tremor, agitation, delusions, hallucinations, fever, tachycardia, diaphoresis, seizures, hyperreflexia * Respiratory alkalosis from hyperventilation * Hypovolemia common * Hypokalemia and hypomagnesemia common Management: * R/O other causes of AMS * head bleed, infxn, GIB, Liver dz, neuro * General measures (can be applied to any alcoholic): * IVF * Thiamine 100mg IV * Multivitamin PO/IV * Magnesium 2-4g IV * Dextrose if needed 1st line medical option: Benzodiazepines (used for all alcohol withdrawals) - GABA agonist: sedates the patient - Valium (diazepam): Fastest onset 1-5 minutes; 5-10mg IV diazepam - Ativan (lorazepam) - Versed (midazolam) - Librium (chlordiazepoxide): PO only, 50-100mg, slow onset and long half life, ideal for outpatient setting Phenobarbital: Barbiturate for benzo-resistant alcohol withdrawal Propofol is preferred induction agent if intubating

Answer 11

-ABCs, O2 PRN, monitor -IV fluids with glucose for CNS hypoglycemia (D5W) -!Decon: Activated charcoal -!Urine alkalinization with !SODIUM BICARB! infusion (urine pH > 8) -check K -> hypokalemia prevents alkalinization -DONT do in CHF or renal failure pts bc of volume load -goal serum pH of 7.45-7.55 or a urine pH of 7.50-8.0 Hemodialysis!: -!!pulmonary edema, cerebral edema (severe confusion/AMS, seizure, coma), renal failure, acidemia, level >100mg/dL (acute) or > 60mg/dL (chronic)

Answer 12

-Aspirin, Oil of WINTERGREEN, Bengay, Air fresheners, mouthwash -Toxic dose = 300mg/kg -!Acute toxicity: N/V, DIAPHORESIS, FEVER, TACHYCARDIA, TACHYPNEA! ** -> RESPIRATORY ALKALOSIS with AG metabolic acidosis -!Chronic toxicity: TINNITUS, GI irritation, AMS*** (think elderly w long term salicylate use with ear ringing, GI sx, AMS, NO HYPERVENTILATION) -Severe: Cerebral and pulmonary edema, HYPOGLYCEMIA causing seizure Labs: - ABG/VBG!!!: -!!Primary resp alk + Anion gap metabolic acidosis****** - -E.g. ↑ pH 7.44 | ↓ PCO2 26 | ↓ HCO3 18 - ASA level: ≥ 30mg/dL - Acetaminophen level, - BMP, - LFTs - POC: hypoglycemia - UA: urine pH LOW (goal: 7.5-8) - Chest xray: check for ARDS and pulmonary edema COD: Cerebral edema (seizure), pulmonary edema (ARDS), metabolic acidosis / resp alk

Answer 13

- ABCs, IV fluids with GLUCOSE for CNS, O2, monitor - ACTIVATED CHARCOAL and URINE ALKALINIZATION with sodium bicarbonate infusion (goal urine pH of 7.5-8) - hemodialysis: if sevewhy re - pulmonary edema - cerebral edema - renal failure - acidemia - altered mental status - level >100mg/dL (acute) or > 60mg/dL (chronic)

Answer 14

- pulmonary edema - cerebral edema - renal failure - acidemia - altered mental status - level >100mg/dL (acute) or > 60mg/dL (chronic)

Answer 15

- chronic subdural hematoma - acute SDH - TBI - MVC

Answer 16

-beta blocker OD -> glucagon, insulin + dextrose, intralipid fat emulsion therapy if refractory -iron- GI upset, kids -> IV crystalloid, antiemetics, whole bowel irrigation, DEFEROXAMINE (severe) -rat poison = warfarin -> lavage, charcoal, vitamin K, FFP, PCC -benzo -> flumazenil* -heparin -> protamine

Answer 17

DECON Airway, Breathing, Circulation Dextrose Elimination Find an antidote (if available) Get a good history if possible WHAT, WHEN and WHY Which drug, dose, amount, immediate vs extended release, co-ingestions Exact time of exposure/ingestion Where they any immediate symptoms? Establish if exposure is acute vs. chronic, history of suicide attempts, illicit drug use, past medical history, other drug use or medication changes Corroborate with EMS, friends, family, neighbors, psych, primary care doctor, pharmacy Comprehensive physical exam  identify toxidrome Vital signs Neurologic: delirium, hyperactivity, obtunded, comatose Eye: pupillary response, nystagmus, lacrimation Skin: Wet or dry/hot GI: Bowel sounds Diagnostic tests should include: POC glucose! - Typical agents that can cause hypoglycemia: - Salicylates - Acetaminophen - Insulin - Oral hypoglycemics - Alcoholism CMP to calculate anion gap and osmol gap VBG for acid-base disturbances Urine or blood drug screen (qualitative , false ±, timeliness) Specific drug levels (APAP, salicylate, dig, anti-seizure, alcohols) ECG Xray - The following are radio-opaque and can sometimes be seen on a KUB Chloral hydrate / cocaine packets Heavy metals Iron Potassium Enteric coated tabs Slow-release forms Poisons have an unpredictable onset and duration of symptoms and toxicity due to many factors: Absorption, elimination, half rate, saturation, metabolism Get help! Call regional poison center (1-800-222-1222) to ensure correct management New York (1-800-764-7667 or 1-800-POISONS)

toxicology Flashcards

(42 cards)