Toxicology

Question 1

Peak time for poisoning in childhood

Answer 1

Toddlers peak time

Adolescents 2nd peak self harm

Question 2

Childhood poisoning

Answer 2

Not usually self harm
History is difficult
Different types of materials ingested eg plant soil paint pesticides drugs
Usually very small amounts are NOT toxic
BUT one pill can kill
Smaller oesphagus and stomach limit the effectiveness of some decontamination
Always consider could this be Child abuse

Question 3

One pill can kill

Answer 3

Amphetamines
B blockers
CCB
Digoxin
Suphonlureas 
Tricyclics antidepressant

Question 4

Other potential killers

Answer 4

Pesticides
Kerr /eucalyptus oil
Campho/ napthalin

Question 5

Poisoning history and examination

Answer 5

History is unreliable
Suspicious
Time of the ingestion unknown (when was the child last well)
Calculate the max possible dose ingested
If >1 child with meds assume all children could have ingested or one did max ingestion

Question 6

Management of poisoning

Answer 6

Resuscitate 
Risk assessment 
Poisoning info 
Ongoing management 
Supportive care and monitoring 
DEAD decontamination/ increasing elimination / antidotes/ disposition

Question 7

Examination of poisoning patient

Answer 7

Id and treat immediate threats to life
Establish the baseline of clinical status 
Corroborate the history 
Consider toxin VS non Toxin causes 
Id complications of poisons 

Full Neurological examination mental state pupils reflexes clonus focal signs
Evidence of trauma
Skin color sweating
Urine retention ? Full bladder ( anticholinergics)

Question 8

Risk assessment in Posioning

Answer 8

What substance eg paradox/ B blocker
Dose 
When  time since ingestion 
Clinical features 
Ix ECG ( TCA) / Sr Paracetamol

Question 9

DD coma /altered state

Non toxic vs toxic

Answer 9

Head injury  
CNS infection 
Hypo/hyperthermia 
Ictal / post Ictal
Drugs
Metabolic BSL /ARF

Question 10

2ary complications of posioning

Answer 10

Aspiration 
Rhabdomyalysis
ARF
Pressure areas
Hypoxic brain injury

Question 11

Drug levels when are they helpful

Answer 11

Paracetamol levels 4 hours after ingestion helpful
Others only when clinically indicated eg phenytoin carbamazepine
Digoxin aspirin lithium

NOT HELPFUL cocain benzo Cocain opiates
ACE/ B Blockers CCB clonidine

Question 12

Anticholinergic toxidromes

Answer 12

Blind as a bat / mad as a hatter /red as beet/ hot as a hare/dry on the bone the bowel and the bladder lose their tone
The heart races alone

Antihistamines TCA / Phenothiazines / Benstropine ( give for maxolon)
Agitated delirium
Dilated pupils 
Full bladder ileus  IDC
Tachycardia

Question 13

Cholinergic Toxidromes
Seen with organophosphate
Chemical attack Vx gas
Carbamates

Answer 13

DUMBELS
Diarrhoea
Urinartion
Miosis
Bronchorrhoea Bradycardia (this is what kills you)
Emesis 
Lacrimation 
Salivation

Question 14

Sympathomimetics. Cocaine exctasy MDMA TCA

Answer 14

Hypertension 
Tachycardia 
Dilated pupils 
Agitation 
Sweating 
Hyperthermia do poorly  treat aggressively 

Pale sweaty patients

Question 15

Serotonin toxicity SSRI SNRI and usually in combination or changes in meds

Answer 15

Neuromuscular examination
Hyper reflexive clonus eyes and ankle examination

Confusion, agitation, dilated pupiles sweating raised BP
Tachycardia

Question 16

Opioid toxicity

Answer 16

Respiratory depression  ( use Naloxone for resp depression NOT CNS depression)
Sedation 
Pinpoint pupils

Question 17

Management of poisoning

Answer 17

Resuscitate ABC
Supportive care
DEAD

Question 18

Supportive care

Answer 18

Metabolic glucose and control the pH
Sedation IV benzodiazepine
Seizures IV benzodiazepine DONT use phenytoin Na+ channel blocker
Body temp cool/ warm
Renal function. Hydration/ haemodialysis

Question 19

DEAD

Answer 19

Decontamination GIT  ( do when the drug is still in the GI tract)
Activated charcoal 
Whole body irrigation. Colonic prep
Endoscopy

Question 20

Activated charcoal

Answer 20

Don’t use in ileus / pt decreased loc
1gm/kg
Taken orally or NG (CXR to check position)
Greatest benefit <=1 hour

Question 21

Complications of activated charcoal

Answer 21

Vomiting
Charcoal aspiration
Absorb the oral antidote
Bowl obstruction/ileu

Question 22

Indications for charcoal

Answer 22

Risk assessment suggests drug ingested would be toxi
Give <= 1hour
Longer if SR meds or LOTS of meds
Co operative pt
Pt has to be alert or the airway protected

Question 23

Contraindications to charcoal

Answer 23

Not for metals alcohol, corrosives , hydrocarbons MATCH
Low GCS
Ileus

Question 24

Whole body irrigation

Answer 24

Metals
Body packers
SR or enteric coated EC CCB
Contraindicated. Bowel obstruction, ileus, / unprotected airway

Question 25

Enhanced Elimination

Answer 25

1 multidose activated charcoal ( enterohepatic circulation) carbamazepine mushrooms 2 urinary alkalization. Salicylate ion trapping 3 heamodialysis use in antifreeze lithium/valproate/ carbamazepine

Question 26

Paracetamol overdose

Answer 26

``` Toxic ingestion >200mg/kg Nomogram SINGLE ingestion Known time of ingestion Level >4hours to ensure peak point IV N acetylcystein antidote ``` Chronic paracetamol overdose and SR overdose over 24-48 hours Complex consult guidelines and toxicologist

Question 27

Clonodine

Answer 27

Clonodine used for ADD CNS depression and bradycardia IV fluids and iv Atropine Naloxine controversial

Question 28

Red back spider bite

Answer 28

Commonest spider bite Local effect pain redness swelling sweating piloerection SYSTEMIC regional pain hypertension sweatiness Treatment is ANALGESIA ++ note the pain can come back Anti venom Not effective Controversial

Question 29

Funnel web spider. FWS ( needs pressure immobilizing and splinting)

Answer 29

Most venomous spider in the world Uncommon to bite 1% of all bites Anti venom works ``` Clinically facilitation of the tongue Tremor parasites Secretions ++ Piloerection N/V/BP pr up cardiac arrhythmia Management ABC IV access Anti venom Admit to icu ```

Question 30

Brown snakes

Answer 30

Commonest cause of snake bite death in Australia All over Australia NOT TASmania Features Collapse a few mins later CPR Consumptive coagulopathy VICC ( coag profile )

Question 31

Tiger snakes and Taipans

Answer 31

Neurotoxic /eyes ptosis and opthamoplegia VICC coagulopathy Give anti venom

Question 32

Death adders

Answer 32

Neurotoxic | NO Coagulopathy

Question 33

First aide for snake bite

Answer 33

``` Do remove from danger Keep still Apply pressure bandage Immobilize the whole limb Splint the limb ( leave the PIB on till A/E and bloods collected and ? AV given if necessary ```

Question 34

Pressure immobilization bandage indications

Answer 34

For ALL snake bites in Australia ( including the sea snake) For Funnel web spider bites Blue ringed octopus Cone shell sting

Question 35

Describe the technique for pressure immobilization bandage

Answer 35

Firm bandage to the bitten site Bandage the entire limb Splint /immobilization of the limb

Question 36

Clinical diagnosis

Answer 36

Geography Circumstances of the bite Symptoms and signs Lab results

Question 37

Anti venoms

Answer 37

Raised in horses Given iv over 30mins ( diluted in NS) Adverse reactions are common Anaphlaxis Sr sickness After one vial given cant take of the bandage and then get lots of blood tests

Question 38

Snake venom detection kids

Answer 38

NOt used much

Question 39

Box jelly fish

Answer 39

Tropical areas often remove Can lead to child deaths Cardiac arrest Remove the testicles and apply vinegar and use Anti venom

Question 40

Blue bottles

Answer 40

Pain responds to HEAT | Put both limbs in hot water to avoid burns