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Flashcards in TOXICOLOGY Deck (74):
1

What is harder to treat – one time single large dose of Tylenol? Or: I took half a bottle today, yesterday, and the day after?

It’s worse if it’s over a time period

2

What should we remember about drugs with a narrow therapeutic windows?

Can become toxic with normal regimen

3

What are some key things we must ask about toxicology?

TIMING of ingestion if key

Talk to EVERYONE (you have to piece it together)

Ask about ALL OTC meds

Count pills

Remember patients may not appear toxic… INITIALLY

4

What entity is your friend/expectation with toxicology and you must consult them every time?

Poison control!

5

What blood test is most likely to change first with poisoning?

INR (will elongate out) then LFT’s

6

What 3 EKG changes are you looking for with poisonings?

High grade blocks, prolonged OT, terminal R wave (lead AVR), and wide QRS

7

What are the toxidromes?

pneumonic that help with syndromes

8

Why should we have a high suspicion for chronic OD in the elderly?

Polypharmacy; or docs not knowing what else they are taking

9

What does MUDPILES stand for?

Methanol,
Uremia,
DKA,
Propylene glycol,
Infection/isonized,
Lactic acidosis,
Ethylene glycol/ethanol, and
Salicylates (aspirin)

10

What is MUDPILES used for?

The elevated anion gap DDx list! Often the bicarb stinks

11

How do you calculate an anion gap?

Sodium, bicarb, and chloride (all in a Chem 8)

Na – (Bicarb + Cl)

12

What’s a normal Anion Gap?

less than 12

13

If a patient presents with delirium, hallucinations, and anxiety are associated with what toxicology?

Chronic Aspirin

14

If a patient presents with hyperventilation (Kussmal), pulmonary edema, tinnitus – what overdose would this be associated with?

Aspirin

15

What do you have Kussmal breathing (bit deep fast respirations)?

They’re trying to correct their metabolic acidosis

16

What is a UDPRO?

Urine drug screen – it’s a yes or no test

17

Can you order an aspirin level?

Yes, serum, and it’s quantitative

18

At what point does aspirin cause serious toxicity?

300-500mg/kg

19

How often are you checking salicylate levels?

Repeat every 2 hours (for 6 hours)– to see when it peaks or declines

20

What other workup do you do for toxicology?

Chemistries, creatinine, calcium, magnesium

ABG

Monitor urine pH

Coag & liver studies

EKG & CXR

21

What do we need to keep their urine levels at?

pH 7.5-8 (via bicarb)

22

Should you see EKG changes with an aspirin overdose?

No

23

Why would we do a chest xr for aspirin OD?

To see if there’s a big clump of pills in their stomach

24

Be careful with serum levels less than 6 hours post ingestion, why?

Because they won’t be absorbing anymore after 6 hours

25

What blood test will change first with aspirin ingestion?

LFT’s

26

What’s the best treatment for aspirin?

BICARB (alkalinize the urine)

Dialysis is the TOC (enhanced elimination, acid-base and electrolyte correction)

Gastric lavage (60 mins post ingestion)

If you give charcoal (within 30 mins) → there’s a risk of aspiration & green-apple poos

27

What are the take home points for aspirin OD?

Consider in the acute altered patient

Look for acidosis

Alkalize urine

Dialysis TOC

28

What’s the max daily dose of Tylenol for an adult?

4 grams!!

29

Why do children do better with Tylenol?

They have more glutathylenol (they can metabolize it better)

30

What other common co-ingestion significantly worsens Tylenol OD? Why?

Alcohol

It uses the same enzyme to metabolize Tylenol & alcohol!!!

31

What’s the most common cause of acute liver failure in the US?

Tylenol

32

What are the 4 phases of Tylenol od?

1 = Asymptomatic

2 = RUQ pain (18-72 hours)

3 = jaundiced, coagulopathy, fatality (72-96) → AKA toxicity is DELAYED

33

What toasts your liver after glutathione is gone?

NAPQl

34

What’s the first sign of Tylenol OD

LFt’s

35

How often do we draw labs for Tylenol od, what do we use with it?

initial + every 4 hours

Rumack-Matthew nomogram (4 hours out)

36

When does the Rumack fail you?

When there is a multiple ingestion over multiple days!

37

What other labs should you test for Tylenol od?

AST/ALT; coag, and glucose

BUN/Cr (to r/o renal failure)

Lactate level (mortality)

ABG (acidosis → shouldn’t be present in a Tylenol od)

Type & Crossmatch

38

How do you treat a tylenol od?

Iv, oxygen, cardiac monitor

NAC (N-acetylcystine) within 8 hours or anytime if pregnant

Consult poison control!

Charcoal within 30 mins

39

At what point do you need a transplant (to the make the list)?

pH 100; serum creatinine >3.4

40

So, what are the take home points with Tylenol od?

use rumack nomogram

Get help if multiple/chronic ingestion

NAC = TOC

Will get sick DAY later

41

What types of meds often have a narrow therapeutic window, and will often become toxic without intentional overdose?

Psych meds = lithium & amitriptyline

42

Agitation, confusion, tremor or rigidity, sweating, hyper-reflexia, anxiety, and ataxia are symptoms associated with what?

Serotonin syndrome (sxs remembered with anticholinergic toxidrome)

43

What labs should you do for serotonin syndrome?

Look for rhabdo (CK)

44

How do you treat serotonin syndrome?

Benzos, BP control, and cooling

45

What’s the biggest complication with opiates?

Respiratory!!!

46

What if you see arrhythmias with opiate od?

They would have to have been down a LONG time (there’s significant neuro damage)

*You don’t see heart problems with opiate od

47

How do we reverse opiates?

narcan (naloxone)

48

What are the extended release opiates?

Dilaudid & Methadone

49

What’s critical about narcan?

IT’s half life is shorter than the opiate half life → Keep them in front of you!!! (otherwise they go into respiratory distress)

50

What is the time to peak effect for opiates?

IV = 10 min

IM = 30

Oral = 90

Transdermal = 2-4 hours (minutes if it touches mucous membranes – they lick it. They will die if ingested)

51

What type of labs should we do for opiate od?

ABC’s, tox screen (but not that helpful), FSBS (finger stick blood sugar), EKG, ABG, CXR

52

How does a person wake up after narcan is administered?

ANGRY

53

If you’ve given narcan and the person is still altered – what do you need to think?

Other ingestion

Methadone will need multiple narcan doses

54

What are the rapidly fatal drugs?

TCA’s, ethylene glycol, Verapamil

55

What’s the most common tricyclic antidepressant?

Amitryptyline

56

What is a classic diagnostic finding of a tricyclic-antidepressants?

EKG = Wide QRS and terminal R wave in aVR

57

What toxidrome is used for TCA OD?

SALT

Shock, AMS, wide (long) QRS, terminal R wave in aVR

It’s bad if they’re in shock, tachy, AMS

58

What is a toxic dose of a TCA, how long dose it take to absorb?

Absorbs in 1 hour

Toxic dose = 10-20mg

59

So, how do we treat TCA OD?

Bicarb!!

Serial EKG’s

Seizure precautions

60

What is ethylene glycol?

Antifreeze

61

How do you OD on ethylene glycol?

Drink it because it tastes sweet

62

What’s the metabolism of ethylene glycol?

EG → Alcohol dehydrogenase → glycolic acid (cause of severe acidosis)

63

If you see kussmal breathing, tachy, AMS (or obtunded), and no other gross abnormalities – is what diagnosis?

Ethylene glycol OD

64

What is the workup for ethylene glycol od?

ABG, ETOH levels, FSBS

65

You order an AG, chem 8, and a serum osmolarity – what do you do next?

Calculated osmolarity

SERUM & CALCULATED OSMOL SHOULD BE THE SAME

66

How do you calculate osmolarity?

2(Na) + BUN level/3 + glucose/18

67

If your serum osmol & calculated osmols don’t match what should you do?

Plug in the conversion factors → if they now match, you have made your diagnosis

68

So how do you treat ethylene glycol?

Fluids, bicarb, FOMEPIZOLE = TOC (expensive, so you give them alcohol or dialysis)

69

So dialysis is for what?

EG & Aspirin

70

What will verapamil cause?

Vasodilation + bradycardia/hypotensive! B/C they are taking a CCB to control their BP!

71

How much verapamil to get an od?

>1gram

72

What is the workup for verapamil?

AG, tox screen, EKG for high grade blocks!

73

How do you treat a verapamil od?

Pacing, CaCL = TOC (reversal agent), also pressor or atropine

74

SO what are the take home points for verapamil od?

Look for bradycardia with severe hypotension

Extended release formulations are the WORST

EKG looking for high grade blocks

Pressor support, 10% CaCL