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Flashcards in Toxicology Deck (19)
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1
Q

Anticholinergic Toxidrome

A

“Red as a beat. Dry as a bone. Hot as a hare. Blind as a bat. Mad as a hatter. Full as a flask.”
Clinical presentation of anticholinergic toxicity
- Anhidrosis
- Anhidrotic hyperthermia/
- Nonreactive mydriasis. Dilated pupils and blurred vision.
- Delirium and hallucinations\
- Agitated
- Seizures
- Reduced urination
- Sinus Tachycardia (May have prolonged QRS and in some cases progress to Torsades De Pointes, VT or VF)
- Decreased or absent bowel sounds

2
Q

Anticholinergic Toxidrome - Pre-hospital Management

A

Pre Hospital

  • Begin by stabilizing airway, breathing and circulation (DRABC). If necessary ventilate and commence CPR.
  • Vital Signs – ECG, SpO2, HR, RR, Temp, EtCO2, BP (Monitor ECG and SpO2)
  • IV Access
  • Supplemental Oxygen
  • Sodium Bicarbonate for prolonged QRS
  • Magnesium Sulphate for Torsades De Pointes
  • Active cooling – Ice packs, exposing, fluids – for severe hyperthermia
  • IV fluids in boluses of 250-500mL for hypotension
3
Q

Anticholinergic Toxidrome - Definitive Management

A

Antidote - Physostigmine. Dose 0.5-2mg IV

  • Usually not required. Most cases can be managed well with supportive cares
  • Other Hospital management: Benzodiazepines and GI decontamination with activated charcoal
4
Q

Cholinergic Toxidrome

A

SLUDGE: Salivation, lacrimation, urination, defecation, gastric emesis (vomiting)
BBB: Bronchorrhea, bronchospasm, bradycardia
- Nicotinic effects - muscle weakness, paralysis
- Cardiac issues - arrhythmias such as heart block and QTc prolongation, ST changes
- Respiratory failure, CNS depression, seizures, lethargy, coma

5
Q

Cholinergic Toxidrome - Managemetn

A
Benzodiazepines
Supportive cares
Atropine
Cooling
Sedaton
6
Q

Serotonergic Toxidromes

A
  • Altered mental status
  • Increased muscle tone
  • Hyperthermia
  • Hyperreflexia
  • Rigidity
  • Tremors
7
Q

Serotonergic Toxidromes - Management

A
  • Benzodiazepines – to control seizures
  • Supportive care
  • Cooling
  • Sedation
8
Q

Serotonergic Toxidromes - Pathophysiology

A
  • Either increase serotonin production/release or inhibit serotonin reuptake
  • SSRIs block reabsorption of serotonin into the pre-synaptic nerve leading to increase of circulating serotonin in the synapse
9
Q

Serotonergic Drugs

A

MAOIs, SSRIs, TCAs and some migraine medications

10
Q

Anticholinergic Drugs

A

Atropine, Tricyclic antidepressants antihistamines, antispasmodics, typical antipsychotics, some parkinsons medications

11
Q

Cholinergic Drugs

A

Nerve gas
Some pesticides (organophosphates)
Can be found in some household products

12
Q

Sympathomimetic Drugs

A
Adrenaline
Cocaine
MDMA (ecstacy)
Ritalin
Caffeine
Pseudoephedrine
Moclobemine
Venlafaxine
Amphetamines
13
Q

Sympathomimentic Toxidrome

A

Sympathetic activation - agitation, mudriasis (dilated pupils), diaphoresis, tremor, tachycardia, hypertension
Cardiovascular - arrhythmias, ACS, aortic dissection, pulmonary oedema
Neurological - intracranial haemorrhage, seizures, psychiatric, agitation, aggression, psychosis
Psychiatric - agitation, aggression
Other - multi-organ fialure, hyperthermia, rhabdomyolysis, hyponataemia

14
Q

Sympathomimentic Toxidrome - Pathophysiology

A

Release of dopamine, epinephrine, norepinephrine and serotonin

  • Norepinephrine causes vasoconstriction by stimulation of alpha-adrenergic receptors on smooth muscle
  • Epinephrine increases myocardial contractility and heart rate by stimulation of beta1-adrenergic receptors
  • Reuptake of stimulatory neurotransmitters inhibited
  • Local anaesthetic - slow nerve impulses by blocking sodium across cell membranes into neuronal pain fibres
15
Q

Sympathomimentic Toxidrome - Management

A
  • Manage ACS, seizures and hyperthermia accordingly
  • Oxygen
  • IV access
  • Midazolam (benzodiazepines very effective) for severe agitation and to sedate
  • Consider analgesia
  • Options for further management: (not pre-hospital protocol as of yet) Sodium bicarbonate for QRS widening, GTN for hypertension and diazepam for hypertension
16
Q

Sympathomimetic Toxidrome - key points

A

rapid sedation with benzodiazepines manages most symptoms
hyperthermia is a high-risk sign
DO NOT give beta-adrenergic agonists as they can cause hypertension

17
Q

Opioid Toxidrome

A
o	Constricted pupils
o	Sedation/ CNS depression
o	Respiratory depression
o	Hypothermia
o	Skin necrosis
o	Compartment syndrome
o	Aspiration
o	Bradycardia and hypotension
o	Decreased bowel sounds
18
Q

Opioid Drugs

A
	Heroin 
	Morphine
	Fentanyl 
	Pethidine
	Oxycodone
	Codeine
	Tramadol
	Benzodiazepines
19
Q

Opioid Toxidrome - Management

A

Oxygen
IPPV
Naloxone (1.6mg single dose, IV 50 mcg PRN)