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Emergency Medicine > Toxicology > Flashcards

Flashcards in Toxicology Deck (108):
1

Initial Evaluation for a Toxicology Patient

ABC's
ABGs as soon as practical
Obtain IV access
Treat coma promptly: glucose, naloxone, thiamine
Maintain circulation
Treat seizures
Cardiac monitoring and pulse oximetry
History

2

Train of Overdose Effects

CNS depression
Myosis
Respiratory depression

3

Medications to Treat Seizures in Toxicology Patients

Diazepam
Phenobarbital

4

Options for Decontamination of Ingested Toxins

Emesis
Gastric lavage
Activated charcoal
Whole bowel irrigation

5

Emesis as a Decontamination Option

Requires gag reflex
Limited efficacy if 1+ hour since ingestion
Ipecac + water

6

Contraindications to Inducing Emesis

Caustics
Low-viscosity hydrocarbons: gasoline, kerosene
Rapid-acting convulsants: meth, cocaine, cyclic antidepressants

7

Indications for Gastric Lavage

Serious ingestions when emesis has failed
Patients are lethargic or uncooperative
Gag-reflex markedly depressed
Patients have ingested rapid-acting convulsants

8

Methodology of Gastric Lavage

Large bore NG tube
Tap water or saline at body temp in 250 mL increments
Continue until fluid returns clear and free of pill fragments

9

What poisons does activated charcoal not adsorb?

P: potassium
A: alcohol
I: iron
L: lithium

10

What are some cathartic actions?

Speeds up GI transit time
Screws up electrolytes
Lots more vomiting
Severe abdominal cramp

11

When is a whole bowel irrigation useful?

Sustained release and enteric coated tablets

12

Initial Laboratory Studies in a Toxicology Patient

ABGs
Chem 7
ECG: wide QRS or prolonged QT
CXR: pulmonary edema
Flat plate abdomen??
Urine for toxicology screen
Draw and hold serum toxicology screens

13

What does management of the patient require in toxicology patients?

Understanding of absorption, distribution, elimination

14

Define First-Order Kinetics

Fixed PERCENTAGE of the toxin is removed per unit of time

15

Define Zero-Order Kinetics

Fixed AMOUNT of toxin is removed per unit of time

16

Define Drug Clearance

Volume of plasma that can be cleared of toxin per unit time

17

When is hemodialysis used in patients who have overdosed?

When toxin is relatively water-soluble and not highly protein bound

18

Indications for Hemodialysis in Overdose Patients

M: methanol
E: ethylene glycol
L: lithium
S: salicylate

19

Advantage of Hemoperfusion over Hemodialysis

Drug/toxin in direct contact with adsorbent material

20

What is hemoperfusion commonly associated with?

Thrombocytopenia

21

What does hemoperfusion NOT do?

Correct electrolyte imbalances
Adjust pH

22

When is hemoperfusion useful?

TRI: TCAs
P: paraquat
E: ethchlorvynol
P: phenobarbital
T: theophylline
D: digitoxin

23

Antidote for Acetaminophen

Acetylcysteine

24

MOA of Acetylcysteine

Bind to NAPQI so it can't accumulate

25

Antidote for Anticholinergics

Physostigmine

26

What other uses are there for physostigmine?

Myasthenia graves
Short term memory

27

Antidote for Benzodiazepines

Flumazenil: if infusion too rapid, patient will seize

28

Antidote for Cyanide

Na nitrite
Na thiosulfate

29

Antidote for Methanol/Polyethylene Glycol (anti-freeze)

Ethanol

30

Antidote for Narcotics

Naloxone (Narcan)

31

Intoxicant for Osmolar Gap Greater than 30

An alcohol

32

Acetaminophen Toxicity

Delayed hepatotoxicity (24-72 hours)

33

How soon should one get an acetaminophen level and begin treatment?

Within the first 16 hours

34

Treatment of Acetaminophen Overdose

Decontaminate
Give activated charcoal
Estimate severity (acetaminophen level)
Acetylcysteine therapy

35

MOA of Acetylcysteine

Substitutes glutathione
Binds NAPQI (metabolite)

36

When should acetylcysteine be administered?

Early
MUST: 12-16 hours
PREFERABLE: 8-10 hours

37

Symptoms of Acetaminophen Overdose Within 4 Hours

Anorexia
N/V
Sweating

38

Symptoms of Acetaminophen Overdose 3+ Days Out

Encephalopathy
Marked elevation in LFTs
Renal failure

39

Symptoms of Acetaminophen Overdose Greater than 1 Week Out

Begin to return to normal

40

Cocaine and Amphetamine Overdose Symptoms

Vasoconstriction
HTN
Bradycardia
Ventricular arrhythmias
Seizure and hyperthermia may produce rhabdomyolysis and myoglobinuria

41

Significant Cocaine Overdose Symptoms

Euphoria
Excitement
Restlessness
Toxic psychosis
Seizures
HTN
Tachycardia
Hyperthermia
Possible MI

42

What drug does cocaine have a synergistic effect with?

Alcohol

43

Treatment of Cocaine or Amphetamine Overdose

GI decontamination
Diazepam
Nitroprusside
Monitor temperature and EKG
+/- head CT

44

Why administer diazepam in cocaine or amphetamine overdose?

Severe agitation or psychosis
Treat seizures

45

Why administer nitroprusside in cocaine or amphetamine overdose?

DBP >120
HTN encephalopathy

46

MOA of Anticholinergics

Block cholinergic receptors both centrally and peripherally

47

Symptoms of Significant Anticholinergic Poisoning

Delirium
Blurred vision
Mydriasis
Hallucinations
Coma
Dry mucous membranes
Inhibition of sweating
Hyperthermia
Tachycardia

48

When would you administer physostigmine in a anticholinergic overdose?

Peripheral and moderate central symptoms

49

Treatment of Anticholinergic Overdose

Supportive care
GI decontamination
Physostigmine (severe symptoms)

50

Conditions with Physostigmine Administration

Atropine available: bradycardia
Must be on cardiac monitor

51

When must you never physostigmine?

TCA overdose
Asthma
Mechanical bowel
Bladder obstruction

52

Main Anticoagulant

Warfarin (Coumadin)

53

MOA of Warfarin (Coumadin)

Block vitamin K dependent clotting factors (II, VII, IX, X)

54

When are peak effects seen with warfarin (Coumadin) overdose?

1-2 days

55

Presentation of Excessive Anticoagulation

Ecchymosis
Hematuria
Uterine bleeding
Melena
Epistaxis
Gingival bleeding
Hemoptysis
Hematemesis

56

Treatment of Excessive Anticoagulation

Supportive therapy
GI decontamination
Baseline PT & repeat in 24-48 hours
Vitamin K IV
FFP in bleeding emergency

57

Examples of Items that Include Arsenic

Insecticides
Rodenticides
Wood preservatives

58

Methods of Arsenic Absorption

Respiratory
GI
Binds with tissue proteins

59

2 Clinical Syndromes of Arsenic Poisoning

Arsenic salt ingestion
Arsine gas inhalation

60

Symptoms of Acute Arsenic Ingestion

Crampy abdominal pain
Vomiting
Profuse watery diarrhea
Burning mucosa
Conjunctivitis
Tremor
Seizures
Garlic odor
Periorbital edema (1-2 days)

61

Symptoms of Chronic Arsenic Ingestion

Peripheral and sensory neuropathy
Malaise
Anorexia
Alopecia
Anemia
Stomatitis

62

Arsine Gas Inhalation Effects

Highly toxic
Rapid intravascular hemolysis
Renal failure

63

Treatment of Acute Arsenic Ingestion Poisoning

GI decontamination
GI lavage
Charcoal
Dimercaperaol (BAL) x 5 days

64

Treatment of Chronic Arsenic Ingestion Poisoning

Penicillamine QID

65

Treatment of Arsine Gas Inhalation

Transfusion
Adequate hydration

66

Diagnosing Mild CO Poisoning

COHgb level
ECG

67

Diagnosing Moderate to Severe CO Poisoning

COHgb level
ABG
Chem 7
Serum lactate
CBC
EKG
Serum CK-MB and troponin
Urine myoglobin
CXR

68

Treatment of CO Poisoning

100% FiO2 for 4 hours

69

Symptoms of CO Poisoning

Fatigue
Malaise
Flu-like
N/V
Confusion
Loss of memory
Emotional lability
Dizziness
Paresthesias
Weakness
Lethargy
Somnolence
Stroke
Coma
Seizures
Respiratory arrest
Chest pain
Myocardial ischemia
Palpitations
Dysrhythmias
Poor cap refill
Hypotension
Cardiac arrest

70

Indications for Hyperbaric Oxygen Therapy Referral

AMS or abnormal near exam
Hx of LOC or near-syncope
Hx of seizure
Coma
Hx of hypotension with exposure
Myocardial ischemia
Hx of prolonged exposure
Pregnant with COHgb levels >15%
Persistent acidosis (relative)
Concurrent thermal or chemical burns (relative)

71

MOA of Digitalis

Enhance cardiac contractility
Slow AV conduction
Enhance automaticity

72

Symptoms of Digitalis Poisoning

Anorexia
N/V
Diarrhea
Abdominal pain
Blurred vision
Color vision disturbance

73

Signs of Digitalis Poisoning

3rd degree AV block
Bradycardia
Ventricular ectopy
Paroxysmal atrial tachycardia with AV block
HYPERkalemia

74

Treatment of Digitalis Poisoning

Glucose + insulin therapy
Bradycardia: atropine, pacing
Ventricular ectopy: lidocaine
Digibind (severe)

75

Symptoms of Excessive Ethanol

Ataxia
Dysarthria
Depressed sensorium
Nystagmus

76

Treatment of Excessive Ethanol

Supportive
Watch blood glucose levels
Thiamine

77

Symptoms of Amatoxin Associated Mushrooms

Severe gastroenteritis
Delayed hepatic and renal failure (48-72 hours)

78

Treatment of Amatoxin Associated Mushrooms

Supportive
Admit to hospital
Baseline renal and hepatic functions

79

Symptoms of Muscarine Associated Mushrooms

Salivation
Miosis
Bradycardia
Diarrhea

80

Onset of Amatoxin Symptoms

6-24 hours

81

Onset of Muscarine Symptoms

30 minutes-1 hour

82

Treatment of Muscarine Associated Mushrooms

Supportive
Atropine (severe)

83

Symptoms of Psilocybin Associated Mushrooms

Hallucination

84

Onset of Psilocybin Symptoms

15-30 minutes

85

Treatment of Psilocybin Associated Mushrooms

Supportive

86

Symptoms of Isotonic Acid and Muscimol Associated Mushrooms

Mydriasis
Tachycardia
Hyperpyrexia
Delirium

87

Treatment of Isotonic Acid and Muscimol Symptoms

Supportive
Physostigmine (severe)

88

Onset of Isotonic Acid and Muscimol Symptoms

30 minutes to 2 hours

89

Symptoms of Monomethylhydrazine Associated Mushrooms

Severe gastroenteritis
Hemolysis
Hepatic and renal failure

90

Onset of Monomethylhydrazine Symptoms

6-12 hours

91

Treatment of Monomethylhydrazine Associated Mushrooms

Supportive
IV pyridoxine

92

SE of Opiates

Sedation
Hypotension
Bradycardia
Hypothermia
Respiratory depression

93

Diagnosis of Opiates

Toxic levels in urine
Reversal of symptoms with naloxone (Narcan)

94

Treatment of Opiate Overdose

Naloxone (Narcan)
Admit to hospital

95

Examples of Organophosphates

Crop sprays
Home insecticides
Bug "bombs"
Flea collars
Chemical warfare agents
Terrorist agents

96

MOA of Organophosphates

Inhibit cholinesterase causing accumulation of acetylcholine

97

Symptoms of Organophosphate Poisoning

Miosis
Excessive salivation
Bronchospasms
Hyperactive bowel sounds
Lethargy
Muscle fasiculation
Seizures
Bradycardia or tachycardia

98

Pneumonic and Meaning for Organophosphate Poisoning Symptoms

D: diarrhea
U: urination
M: miosis
B: bronchospasms
E: excitation
L: lacrimation
S: salivation

99

Treatment of Organophosphate Poisoning

Decontamination
Airway management
IV Atropine
Pralidoxime (2-PAM)
Admit to hospital
Avoid future exposures

100

Methods of Bringing Phencyclidine (PCP) into the Body

Smoked
Snorted
Ingestion
Injection

101

What type of agent is Phencyclidine (PCP)?

Sympathomimetic
Hallucinogenic
Dissociative agent

102

Symptoms of Phencyclidine (PCP)

Vertical and horizontal nystagmus
HTN
Tachycardia
Hyperthermia
Marked muscle rigidity
Dystonias
Seizures

103

Goals of Treatment

Limit seizures
Limit violence

104

Treatment of Phencyclidine (PCP) Overdose

Diazepam
Haloperidol
Monitor and prevent rhabdomyolysis

105

What is the worst overdose to care for with the absolute worst outcomes regardless of skill?

TCAs

106

Symptoms of TCA Overdose

Mydriasis
Dry mouth
Tachycardia
Agitation
Hallucinations
Coma
Refractory seizures
Widening of QRS
Prolonged QT and PR intervals
Possible AV block
Torsades possible
Hypotension

107

3-Cs of TCA Toxicity

Cardiac abnormalities
Convulsions
Coma

108

Treatment of TCA Toxicity

Gastric lavage
Instill charcoal
Continuous cardiac monitoring
Diazepam (seizures)
Lidocaine (ventricular arrhythmias, hypotension)